摘要
目的探究信息化护理病历在急诊监护室患者中应用价值。方法选取医院急诊监护室2016年10月-2017年9月收治的100例患者作为研究对象,所有患者均应用信息化护理病历进行护理管理,将其作为观察组,同时选取院内2015年10月~2016年9月收治的100例未采取信息化护理病历进行护理管理患者作为对照组,对比2组患者不同干预后不良事件发生情况、患者压疮评分表评分(Braden)、疼痛评分(VAS)、日常生活能力评分(ADL)、护理质量及病历质量评分、患者满意率。结果观察组不良事件发生率为1.0%,明显低于对照组7.0%,满意率为98.0%,明显高于对照组90.0%;观察组患者Braden、VAS、ADL评分均优于对照组,患者护理质量及病历质量评分均明显高于对照组。结论信息化护理病历的应用可降低急诊监护室患者护理过程中不良事件发生率,提升临床护理质量及病历治疗,患者满意率高,可推广应用。
Objective To explore the application value of information nursing medical records in emergency care.Methods To select hospital emergency care unit in October 2016-2016 of 100 patients admitted in September as the research object, the nursing records of all patients applied informatization management, as a group, and select hospital in October 2015 to September 2016 were information nursing medical records of 100 cases of failure to nursing management of patients as control group, compared two groups of patients with different adverse events after intervention, patients with pressure ulcer assessment score（Braden）, pain score（VAS）, daily life ability score（ADL） and quality of care and medical records quality scores, patient satisfaction. Results The incidence of adverse events in the observation group was 1.00%, significantly lower than the control group of 7.00%, and the satisfaction rate was 98.00%, significantly higher than the control group 90.00%. In the observation group, Braden, VAS and ADL score were all better than the control group. The quality of nursing care and the quality of medical records were significantly higher than those in the control group. Conclusions The application of information nursing medical record could reduce the incidence of adverse events in the nursing process of emergency care patients, improve the clinical nursing quality and medical record treatment, and the patient＇s satisfaction rate could be promoted and applied.
作者
王庆玲
Wang Qingling(Xuanwu Hospital, Capital Medical University, Beijing 100053, Chin)
出处
《中国病案》
2018年第3期19-21,共3页
Chinese Medical Record
关键词
信息化护理病历
急诊监护室
管理安全
不良事件
Information nursing medical records
Emergency care unit
Management safety
Adverse events
