我国电子护理文书系统的发展与设想

Development and Imagination on Electronic Nursing Document System in China

医疗记录的电子化是医疗信息化的关键体现,而电子护理文书是电子化医疗记录的关键部分。目前的电子护理文书系统已被广泛应用。不同医院或厂商的电子护理文书系统各有特点,也存在着一些可以优化的地方。优化的电子护理文书系统能使护士更加高效、精确地完成护理文书的书写记录。本文主要综述我国电子护理文书系统的外观、数据处理和人性化关怀的发展现状,同时对该领域的发展作出展望,以期为电子护理文书系统的优化提供帮助。

Electronic medical record is the key embodiment of medical information,and electronic nursing documents are the key part of electronic medical record.The current electronic nursing document system has been widely used.The electronic nursing document systems of different hospitals or manufacturers have their own characteristics,and there are also some places that can be optimized.The optimized electronic nursing document system enables nurses to complete the writing records of nursing documents more efficiently and accurately.This paper mainly reviews the development status of appearance,data processing and humanized care of electronic nursing document system in China,and prospects the development of this field so as to provide help for the optimization of electronic nursing document system.