电子护理文书质量控制的研究

Applying information technology to electronic nursing records quality control

目的探索电子护理文书质量控制系统的设计、应用及效果。方法根据文书规范要求,设计质量控制点,通过计算机程序自动监控电子文书记录,列出问题。从电子护理文书得分及使用人员看法两方面评价其运行效果。结果质量控制系统运行半年后,电子护理文书得分由81.32分上升至97.36分(P<0.001),所有访谈人员均对质量控制系统给予了肯定。结论电子护理文书质量控制系统提高了质量控制效率和管理效果,提升了电子护理文书质量。

Objective To explore the design,application and effects of electronic quality control system for nursing records. Methods The key points of quality control were identified according to the standards of nursing records and were monitored by computer program automatically. The quality of electronic nursing records and nurses＇ appraisal were investigated. Results The quality of electronic nursing records increased from 81.32 to 97.36 （P〈0.001）. Nurses showed high appraisal on the quality control system. Conclusion The electronic nursing records quality control system can improve the quality control efficiency and management effectiveness and promote the quality of electronic nursing records.