表格式产科电子护理病历平台的构建及应用研究

目的探讨表格式产科电子病历平台的构建及应用效果。方法 2012年3月~2013年3月期间抽取我院产科200份护理病历,随机将其分为对照组(传统手工记录)和观察组(表格式电子记录)各100份,对两组病历书写质量评分、记录时间以及体温表绘制、医嘱处理耗时进行评估和比较。结果与对照组相比,观察组病历书写质量评分明显提高(94.0±2.0 vs 89.5±2.0),记录时间显著缩短(4.8±1.5 vs 10.0±3.5),体温表绘制耗时(15.0±0.5 vs83.0±2.0;0.2±0.0 vs 1.2±0.1)及医嘱处理耗时(80.5±3.0 vs 188.0±6.0;1.1±0.1 vs 2.8±0.1)均明显减少,差异有统计学意义(P<0.05)。结论表格式电子护理病历有效提高产科护理病历的质量,明显提高护理满意度,值得临床推广应用。

The construction and application of the electronic tabular nursing record platform in obstetrical department

Objective To study the construction and application effect of the electronic tabular nursing record platform in obstetrical department. Methods The 200 nursing.records in our obstetrical department during the period from March 2012 to March 2013 were randomized into the control group（traditional manual records）and the observation group（electronic tabular nursing records）, 100 nursing records per group. The scores of records writing quality,records time,body tem- perature chart and medical order in the two groups were evaluated and compared. Results Compared with the control group, the scores of records writing quality were significantly increased （94.0±2.0 vs 89.5±2.0）,the records time was obviously redueed（4.8±1.5 vs 10,0±3.5）,the time of body temperature chart（15.0±0.5 vs 83.0±2.0;0.2±0.0 vs 1.2±0.1） and medical order （80.5±3,0 vs 188.0±6.0; 1.1±0.1 vs 2.8±0.1 ）were significantly reduced in the observation group with statistical difference （P〈0.05）. Conclusion The electronic tabular nursing record can effectively improve the quality of nursing records in obstetrical department, significantly increase the nursing satisfaction degree, and is worthy of clini- cal promotion.