基于电子病历平台构建压疮信息管理系统

Construction of Bedsore Information Management System Based on Electronic Medical Record Platform

目的将压疮管理信息化,为临床防治和监控压疮提供依据,提高压疮上报的及时性和准确性。方法通过利用电子病历平台构建压疮信息管理系统,实行责任护士-病房护士长、科护士长-护理部三级管理模式,管理者对压疮上报信息资料进行评价监控、统计分析,实行全面实时的质量管理。结果与纸质填写上报相比较,压疮信息管理系统上报及时准确,病历资料完整规范。上报及时率由2014年的86.25%提高至2015年100%;难免压疮发生率由2014年的36.17%降低至2015年的27.81%。结论基于电子病历平台构建的压疮信息管理系统,促进压疮管理信息化,是实现压疮防治与监控管理的有效手段,提高了压疮护理质量的管理效能。

Objective Bedsore management information provides a basis for clinical prevention and bedsore monito- ring and improves the timeliness and accuracy of bedsore report. Methods Bedsore information management system by means of electronic medical record platform was constructed to implement three - class management mode of duty nurse - head nurse and bead nurse of the department - nursing department. The management adopts evaluation, monitoring, statistics and analysis towards bedsore information data reported to implement comprehensive and real -time quality management. Results Compared witb the filled papery report, bedsore information management system reported timely and accurately and made medical records complete and normative. The rate of timely reporting increased from 86.25% in 2014 to 100% in 2015, and bedsore incidence decreased from 36.17% in 2014 to 27.81% in 2015. Conclusion Promoting bedsore management infor- mation with bedsore management system based on electronic medical record platform is an effective means to fulfill bedsore prevention and control management and improves the management effectiveness of bedsore nursing quality.