基于电子病历的护理干预对血液透析患者的临床应用

Clinical Application of Nursing Intervention Based on Electronic Medical Records in Hemodialysis Patients

目的:探讨基于电子病历(EMR)的护理干预对血液透析患者的临床应用。方法:选取2016年1月至2017年12月我院肾内科进行血液透析患者126例作为研究对象,基于电子病历采用电子化护理干预血液透析患者,比较护理前后医嘱执行情况、疲乏情况、生活质量。结果:护理前后对比,临时医嘱平均执行时间明显降低(P<0.05),护理后医嘱执行率、医嘱遗漏率及护理差错率显著优于护理前,差异具有统计学意义(P<0.05);护理后患者疲乏状况较护理前明显降低,差异具有统计学意义(P<0.05);护理后患者身体活动、心理活动、管理行为、限制行为等生活质量指标较护理前明显提高,差异具有统计学意义(P<0.05)。结论:基于电子病历的电子化护理干预为血液透析中心提供实时性的动态管理系统,可提高患者医嘱执行率,改善患者疲乏状况与生活质量,利于临床预后。

Objective:To explore the clinical application of EMR(electronic medical record)-based nursing intervention in patients with hemodialysis.Methods:A total of 126 patients with hemodialysis were enrolled in our hospital from January 2016 to December 2017.Based on the electronic medical records,patients with hemodialysis were treated with electronic nursing.The implementation of medical advice,fatigue condition and quality of life were compared before and after treatment.Results:Before and after nursing,the average implementation time of temporary medical records was significantly lower(P<0.05).The implementation rate,omission rate and error rate of medical orders after nursing were significantly better than those before nursing(P<0.05).The fatigue status of patients after nursing was significantly lower than that before nursing(P<0.05).The quality of life indicators such as physical activity,psychological activity,management behavior,and restrictive behavior of the patients after nursing were significantly improved compared with the pre-treatment,and the differences were statistically significant(P<0.05).Conclusion:The EMR-based nursing intervention provides a real-time dynamic management system for the hemodialysis center,which can improve the medical advice implementation rate,improve the fatigue status and quality of life,beneficial to clinical prognosis.