| 临床护理记录电子模板的开发与应用 |
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| 引用本文： | 王瑜,王秀珉,邹佩珍,李晓茵,陈盈盈.临床护理记录电子模板的开发与应用[J].护理管理杂志,2007,7(7):52-53. |
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| 作者姓名： | 王瑜 王秀珉 邹佩珍 李晓茵 陈盈盈 |
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| 作者单位： | 1. 解放军第180医院,骨一科,福建,泉州,362000
2. 解放军第180医院,护理部,福建,泉州,362000 |
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| 摘 要： | 目的研究护理记录电子模板在临床应用的可行性,为提高护理文书质量提供保证。方法按照《病历书写基本规范(试行)》的要求,在计算机上开发护理记录模板,套入"军字1号"病程记录续版进行临床护理记录书写。结果提高了工作效率,且操作简单快捷,护理文书质量明显提高。结论护理记录电子模板在临床应用具有可行性,能促进我国护理信息化发展的进程。
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| 关 键 词： | 护理记录 电子模板 临床应用 |
| 文章编号： | 1671-315X(2007)07-0052-02 |
| 修稿时间： | 2006年12月13 |
The design and application of electronic template for nursing records |
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| WANG Yu,WANG Xiu-min,ZOU Pei-zhen,LI Xiao-yin,CHEN Ying-ying.The design and application of electronic template for nursing records[J].Journal of Nursing Administration,2007,7(7):52-53. |
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| Authors: | WANG Yu WANG Xiu-min ZOU Pei-zhen LI Xiao-yin CHEN Ying-ying |
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| Abstract: | Objective To study the feasibility of the electronic template for nursing records,and to ensure the quality of nursing records,Methods Ac- cording to"Basic standards for medical records(try- out)",and based on the nursing information system of No,1 project of PLA,an electronic template for nursing records was developed and applied in clinical practice,Results The electronic nursing records were more faster and simpler than handwriting and remarkably improved the efficiency and quality of nursing records,Conclusion The electronic template for nursing records is proved to he feasible in clinical practice,which can promote the advancement of nursing information. |
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| Keywords: | nursing records electronic template application |
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