电子护理病历的应用及质量控制

目的探讨电子护理病历的应用效果及质量控制，使电子护理病历记录更具规范化、科学化。方法随机抽查我科2007年5月～8月电子护理病历和手写护理病历各100份，分为电子护理病历组和手写护理病历组。观察两组护理病历记录时间及存在的质量缺陷，然后举办护理病历书写培训班，制定书写规范，召开研讨会分析存在的问题、原因，并提出改进措施。结果电子护理病历记录时间相应减少，漏记、涂改、欠整洁等质量缺陷亦明显减少，与手写记录比较有显著性差异（P〈0．05）。结论电子护理病历的应用使护士书写方便、快捷，加强质量监控，能有效提高护理病历质量。

The Application and Quality Control of Electronic Nursing Medical Record

Objective To explore the application and quality control of electronic nursing medical record and make it more standard and scientific. Methods 100 electronic and writing nursing medical record which were respectively sampled from May to August of 2007 were randomly arranged to the experiment group and the control group. Observed the record times and exisited quality problems and then held the training of nursing medical record, formulated writing standard and convoked seminar to analyze the existed problems and reasons, furthermore, raised improved measures. Results There were significant differences between the electronic and writing nursing medical reeord（P〈0. 05）. The electronic nursing medical record showed a decreased record time, less leak, smear and disorder. Conclusion The application of electronic nursing medical record makes nurses write more convenient and quick. Strengthen the control of quality can effectively improves the quality of nursing medical record.