围术期电子护理记录单对护理记录书写质量的影响

Effect of Perioperative Electronic Nursing Record Sheet on Writing Quality of Nursing Record

目的分析神经外科围术期应用电子护理记录单的护理记录情况,以提高护理记录单书写质量。方法随机抽取某院2018年1月1日-2019年10月31日期间,神经外科纸质护理记录单90份作为纸质组,抽取2020年1月1日-2020年12月31日期间,神经外科使用围术期电子护理记录单的护理记录90份作为电子组,比较两组护理记录单书写缺陷发生情况,比较两组护理记录单书写时效性、完整性和正确性及书写质量评分,并对围术期电子护理记录单实施前后护理人员满意度进行比较。结果电子组护理记录缺陷存在空项目占1.11%、缺乏连续性和动态性占1.11%、医学术语不规范占0%、出入量记录不一致占0%、与麻醉单内容不一致占0%、有涂改或刮痕占0%,缺陷例数明显少于纸质组(8.89%,11.11%,13.33%,10.00%,8.89%,10.00%),P<0.05,差异有统计学意义;电子组护理记录单完成时效性占100%、完整性占98.89%和正确性占96.67%,明显高于纸质组(74.44%,75.56%、72.22%)、电子组书写质量评分(96.74±10.23)分高于纸质组(89.66±9.42)分,P<0.05,差异有统计学意义。围术期电子护理记录单实施后护理人员总满意度100%高于实施前80.00%,P<0.05,差异有统计学意义。结论围术期电子护理记录单可提高神经外科护理人员书写质量评分,减少书写缺陷发生率,提高护理记录单完成时效性、完整性和正确性,且护理人员满意度较高,值得临床进一步推广应用。

Objectives This study aims to use electronic nursing records to document nursing records in the perioperative period of neurosurgery,in order to achieve the purpose of improving the writing quality of nursing records.Methods 90 copies of paper nursing records from a hospital from January 1,2018 to October 31,2019 were randomly selected as the paper group,and 90 nursing records using perioperative electronic nursing record sheets from January 1,2020 to December 31,2020 were randomly selected as the electronic group.The occurrence of writing defects,the writing timeliness,completeness and correctness,and writing quality scores of the nursing records in the two groups were compared.The satisfaction of nurses before and after the implementation of perioperative electronic nursing records was compared.Results Nursing record defects in the electronic group accounted for 1.11%,lack of continuity and dynamics accounted for 1.11%,non-standard medical terminology accounted for 0%,inconsistencies in access records accounted for 0%,inconsistencies with anesthesia sheets accounted for 0%,and having alterations or scratches accounted for 0%and other defects were significantly less than the paper group(8.89%,11.11%,13.33%,10.00%,8.89%,10.00%).The difference was statistically significant(P<0.05).The timeliness of completion of nursing records in the electronic group accounted for 100%,the completeness accounted for 98.89%,and the correctness accounted for 96.67%,which were significantly higher than the paper group(74.44%,75.56%,72.22%).The writing quality score of the electronic group(96.74±10.23)was higher than that of the paper group(89.66±9.42),and the difference was statistically significant(P<0.05).After the implementation of the perioperative electronic nursing records,the total satisfaction of nursing staff was 100%higher than that before the implementation of 80.00%,and the difference was statistically significant(P<0.05).Conclusions The perioperative electronic nursing record sheet can improve the writing quality score of neurosurgery nurses,reduce the incidence of writing defects,improve the timeliness,completeness and correctness of the nursing record sheet,and the satisfaction of nursing staff is high,which is worthy of further clinical application.