摘要
目的探讨专科专病电子护理记录单的应用方法与效果。方法设计一般护理记录单、7个专科表格和9种专病表格电子模块,在全院推广使用,并评价效果。结果应用电子护理记录单后,缩短了护士护理文书的书写时间,提高了文书书写质量(P<0.01或P<0.05)。结论根据不同疾病、不同专科设计不同的电子护理记录单,是临床可行的护理记录方式。
Objective To explore the application and effects of specialist and specific disease electronic nursing records. Methods General nursing records, 7 specialist forms and 9 special disease forms were designed and applied in the hospital, Then, the effects were evaluated. Results After the application of electronic nursing records, the time of writing nursing records was reduced and the quality of writing was improved （P 〈 0. 01 or P 〈 0. 05 ）. Conclusion Nursing electronic records desi^ned for different diseases and departments is feasible to be applied in clinical practice.
出处
《护理管理杂志》
2013年第1期69-70,共2页
Journal of Nursing Administration
关键词
护理记录
电子表格
管理
nursing records
electric table
management
