电子护理文书质量评价标准的构建

The establishment of nursing electronic records＇ quality evaluation standard

目的构建电子护理文书质量评价标准。方法通过查阅国内外相关文献，应用德尔菲专家咨询法，依据广东省卫生厅制定的护理文书规范，制定基于临床护理工作的电子护理文书评价标准的项目与细则。结果专家咨询的权威程度系数为0．82，判断系数为0．84，熟悉系数为0．79；最终确定护理文书评价标准包括入院时和入院后两部分，入院时部分包括4项一级指标和13项二级指标，入院后部分包括3项一级指标和10项二级指标。本研究第一轮函询中，一级指标和二级指标的协调系数分别为0．320、0．358，第二轮函询中，一级指标和二级指标的协调系数分别为0．564、0．387，协调系数比较差异有统计学意义（P〈0．01）。结论应用德尔菲专家咨询法构建的电子护理文书评价标准可为临床护理管理者提供评价标准。

Objective To establish nursing electronic records＇ quality evaluation standard. Methods Through the review of related literature at home and abroad, with the application of Delphi expert consultation method, on the basis of nursing documents specification formulated by the health department of Guangdong Province, established the projects and detailed rules of evaluation criteria of nursing electronic documents based on clinical nursing documents. Results The expert＇s authority coefficient was 0.82, the judgment coefficient was 0.84, the familiarity coefficient was 0.79; the evaluation criteria included two parts： admission and after admission indexes. At the first round of this study, the project coordination coefficient of first grade indexes and second grade indexes were 0.320, 0.358; at the second round, the project coordination coefficient of first grade indexes and second grade indexes were 0.564, 0.387, with statistically significant differences （P〈0.01）. Conclusion The evaluation criteria for nursing documents can be used as the standard for clinical management.