摘要
目的设计电子特护记录单,评价应用效果。方法基于临床信息系统设计电子特护记录单并在神经科ICU应用,对比2017年4月-6月87例电子特护记录单与2016年12月-2017年2月95例纸版特护记录单的书写质量得分,并分别记录60人次白班护士用于书写两种特护记录单的时间。结果白班护士平均每班次用于书写纸版和电子特护记录单的时间分别为64.3±16.8分钟和42.8±10.2分钟,纸版和电子特护记录单书写质量得分分别为90.7±9.1分和95.3±7.4分。两种特护记录单在书写时间、书写质量方面的差异均有统计学意义(P<0.05)。结论应用ICU电子特护记录单后,能缩短护士用于书写护理记录的时间,书写质量显著提高,有助于提高临床护理质量。
Objective To apply and evaluate an electronic nursing records sheet in intensive care unit.Methods A nursing records sheet was designed applied in Neurological Intensive Care Unit. Writing quality were compared between 87 electronic nursing records sheets and 95 handwriting ones. Time was recorded that day shift nurse used to write sheets, 60 cases each. Results The average writing time of handwriting sheets and electronic ones were 64.3±16.8 and 42.8±10.2 minutes（P0.05）, respectively. And the average writing quality scores of these two nursing records sheets were 90.7±9.1 and 95.3±7.4（P0.05）, respectively. Conclusion The electronic nursing records sheet could significantly improve work efficiency and quality, and would probably benefit clinical nursing care.
作者
唐艳军
丁舒
Tang Yanjun;Ding Shu(Nerve ICU of Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China)
出处
《中国病案》
2017年第12期18-20,共3页
Chinese Medical Record
关键词
重症监护病房
护理记录
管理
效果
Intensive Care Unit
Nursing records
Manage
Effect
