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| 专科专病电子护理记录单的设计与应用 | |
| 引用本文： | 宋雁宾,王曼,张玲,亢君.专科专病电子护理记录单的设计与应用[J].护理管理杂志,2013,13(1):69-70. |
| 作者姓名： | 宋雁宾 王曼 张玲 亢君 |
| 作者单位： | 1. 解放军总医院护理部,北京市,100853 2. 解放军总医院第一附属医院急救部,北京市,100048 3. 解放军总医院第一附属医院护理部,北京市,100048 |
| 摘 要： | 目的探讨专科专病电子护理记录单的应用方法与效果。方法设计一般护理记录单、7个专科表格和9种专病表格电子模块，在全院推广使用，并评价效果。结果应用电子护理记录单后，缩短了护士护理文书的书写时间，提高了文书书写质量（P〈0．01或P〈0．05）。结论根据不同疾病、不同专科设计不同的电子护理记录单，是I』缶床可行的护理记录方式。 |
| 关 键 词： | 护理记录 电子表格 管理 |
Design and application of specialist and specific disease electronic nursing records |
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| SONG Yan-bin , WANG Man , ZHANG Ling , KANG Jun.Design and application of specialist and specific disease electronic nursing records[J].Journal of Nursing Administration,2013,13(1):69-70. | |
| Authors: | SONG Yan-bin WANG Man ZHANG Ling KANG Jun |
| Institution: | 1.Nursing Department,General Hospital of People’s Liberation Army,Beijing 100853,China;2.Emergency Department,First Hospital Affiliated to General Hospital of People’s Liberation Army,Beijing 100048,China;Nursing Department,First Hospital Affiliated to General Hospital of People’s Liberation Army,Beijing 100048,China |
| Abstract: | Objective To explore the application and effects of specialist and specific disease electronic nursing records. Methods General nursing records, 7 specialist forms and 9 special disease forms were designed and applied in the hospital, Then, the effects were evaluated. Results After the application of electronic nursing records, the time of writing nursing records was reduced and the quality of writing was improved （P 〈 0. 01 or P 〈 0. 05 ）. Conclusion Nursing electronic records desi~ned for different diseases and departments is feasible to be applied in clinical practice. |
| Keywords: | nursing records electric table management |
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