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重症护理观察记录智能化模式之优化
引用本文:刘薇群,吕剑虹,肖松梅,江会,王小芳,罗玲,程卢山.重症护理观察记录智能化模式之优化[J].中国护理管理,2011,11(6):51-52.
作者姓名:刘薇群  吕剑虹  肖松梅  江会  王小芳  罗玲  程卢山
作者单位:1. 上海市东方医院护理部,200120
2. 上海市东方医院中心ICU,200120
3. 上海市东方医院心血管ICU,200120
4. 上海市东方医院ICU,200120
5. 同济大学医学院
摘    要:目的:通过信息技术,完善系统智能化建设,有效提高重症护理观察记录的效率和质量。方法:确定研究建立的需求,完成系统优化。结果:完成对重要、典型数据的跟踪、记录;护理措施"一键式"录入等8个项目的建立、改进;试用半年,ICU责任护士减少记录时间约70min;用视觉模拟评分法进行评价,护士认可度达9.2分。结论:减少责任护士的记录时间,减轻护士的工作压力,改善重症护理观察记录的质量。让护士有更多的时间和精力,为病人提供直接护理,为病人得到优质护理服务提供保证。

关 键 词:重症护理  信息化  护理书写

Model optimization of intensive care observation records
LIU Wei-qun,LV Jian-hong,XIAO Song-mei,Nursing.Model optimization of intensive care observation records[J].Journal of Chinese Nursing Management,2011,11(6):51-52.
Authors:LIU Wei-qun  LV Jian-hong  XIAO Song-mei  Nursing
Institution:LIU Wei-qun,LV Jian-hong,XIAO Song-mei,Nursing Department,Shanghai East Hospital,Shanghai,200120 China
Abstract:Objective: To improve recording efficiency and quality of the intensive care observation through information technology and construction of system intellectualization.Methods:We determined developing needs and completed system optimization. Results:We developed and improved eight projects, including tracking and recording important andtypical data and a key type recording system of nursing intervention etc. We had put thesystem on trial for half a year and the results showed that it could reduce primary nur...
Keywords:Intensive care  informatization  nursing records  
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