儿内科护理记录电子版的构建与应用研究

Application of electronic nursing record in qualified pediatric nursing

目的探讨儿内科护理记录电子版在临床应用的效果。方法利用医院计算机信息系统,根据儿科特点设计表格和文字书写相结合的儿内科护理记录电子版,2011年10—12月间,每月随机抽取上海交通大学附属第六人民医院儿内科护理病历各50份,连续3个月,两种不同书写记录各150份,同期比较电子版与纸质版护理记录单的书写时间与质量。结果护理记录电子版的书写时间明显少于纸质版护理记录单,护理文件书写质量明显高于纸质版护理记录单,两组比较,差异有统计学意义(P<0.05)。结论使用儿内科护理记录电子版操作简单、格式规范、时效性强、可在线保存并随时查阅,减少护士书写时间;同时保证护理文件书写质量,实现信息化管理。

Objective To investigate the effect of electronic nursing record system in qualified pediatric nurs- ing. Methods The electronic nursing records well designed by the hospital computer information system were compared with the traditional paper records in the department of paediatrics in our hospital from October to De- cember 2011. Results The record time spent in electronic nursing records was obviously shorter than that in traditional paper records, and the writing quality of electronic nursing records was much better （ P 〈 0.05 ）. Conclusion With the merits of simple control, specialized format, timeliness, stored online and easy checkout, the electronic nursing records can significantly reduce the record time and ensure high writing quality, to achieve electronic management.