摘要
目的探讨医院信息系统(HIS)下结构化经外周插管的中心静脉导管(PICC)专科护理记录单的设计与应用,为患者提供高层次和专业化服务。方法选取2023年1月至3月九江市第一人民医院的60例门诊患者作为研究对象,根据就诊顺序将其分为对照组(n=30)和观察组(n=30)。基于HIS设计,并采用专科护理门诊的高级护理实践模式,拟设计HIS下结构化PICC专科护理记录单,与传统门诊病历记录模式进行比较。比较两组的记录时间、数据质量、数据统计便捷性等方面。结果观察组PICC护理书写时间和检查时间等记录时间短于对照组,差异有统计学意义(P<0.05);观察组关于完整性、易读性、可溯性得分和数据质量总分高于对照组,差异有统计学意义(P<0.05);观察组关于局部皮肤情况、针眼情况、导管刻度、导管冲封管情况和贴膜敷料情况等PICC护理数据便捷性得分高于对照组,差异有统计学意义(P<0.05)。结论采用HIS下结构化PICC专科护理记录单进行PICC护理记录,有助于提高数据质量、数据统计便捷性,缩短护理记录时间。
Objective To explore the design and application of structured peripherally inserted central catheter(PICC)specialist nursing record sheet under hospital information system(HIS)so as to provide high-level and professional services for patients.Methods A total of 60 outpatients in JiuJiang NO.1 People's Hospital were enrolled as the research objects between January and March 2023.According to the admission order,they were divided into control group(n=30)and observation group(n=30).Based on HIS design and the advanced nursing practice mode in nurse-led clinics,structured PICC specialized nursing record sheets under HIS were designed and compared with the traditional outpatient medical record mode.The record time,data quality and data statistics convenience of the two groups were compared.Results The recording time of PICC nursing(writing time,examination time)in observation group were shorter than those in control group,the differences were statistically significant(P<0.05).The scores of integrity,legibility and traceability,and total score of data quality were higher than those in control group,the differences were statistically significant(P<0.05).The scores of PICC nursing data convenience(local skin conditions,needle eye conditions,catheter calibration,catheter sealing conditions and dressing conditions)were higher than those in control group,the differences were statistically significant(P<0.05).Conclusion The application of structured PICC specialist nursing record sheet under HIS in PICC nursing record is beneficial to improve data quality and data statistics convenience,and shorten nursing record time.
作者
刘燕
梁芳
黎洪群
LIU Yan;LIANG Fang;LI Hongqun(PICC Specialist Nursing Clinic,JiuJiang No.1 People's Hospital,Jiangxi Province,Jiujiang 332000,China)
出处
《中国当代医药》
CAS
2024年第13期139-142,共4页
China Modern Medicine
基金
江西省卫生健康委科技计划项目(202311477)。
关键词
医院信息系统
经外周插管的中心静脉导管
专科护理记录单
Hospital information system
Peripherally inserted central catheter
Specialist nursing record sheet
