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融合结构式外科监护室电子护理记录单的设计与应用

Design and application of integrated and structural electronic nursing records in SICU

摘要:

目的 探讨融合结构式外科监护室(SICU)电子护理记录单的设计及应用效果.方法2015年1月起依托医院HIS系统、监护仪,与麦迪斯顿公司合作,将两者融合一体设计运行结构式SICU电子护理记录单.经过为期6个月的调试、磨合与试运行,至2015年7月电子护理记录单完全替代原纸质记录单.在替代之前10 d内,比较护士分别花在420份手写版和电子版护理记录的用时与错误率情况;同时在电子护理记录单全面运行3个月后,通过抽样访谈了解护士的满意度与使用体验.结果护士用于电子护理记录单420份的记录时间由纸质版的(43±11)min缩短为(30±10)min,差异有统计学意义(t=16.543,P<0.01);错误率由20.48%(86/420)减少为10.24%(43/420),差异有统计学意义(χ2=16.934,P<0.01);运用电子护理记录单后护士满意度反馈显著提高,由以往的90%(36/40)提高到100%(40/40),差异有统计学意义(U=7.112,P<0.01);护士们认为电子护理记录显著优于手写记录,一方面监护仪监测数据等可以直接导入,避免书写错误的同时减轻了工作量,另一方面因实现了所有数据永久储存在HIS系统,因此,通过患者ID号与时间的输入医护人员可以随时检索并了解患者的病情状况.结论电子护理记录单较纸质版能更为真实、及时、客观、全面地反映SICU患者病情变化,具有规范、便捷、省时等优点,提高了护士工作效率,利于医护人员更为直观地了解患者病情动态、评价护士工作质量,实现原始数据永久保留.

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abstracts:

Objective To evaluate the design and effectiveness of electronic nursing records. Methods The integrated and structural electronic nursing records of SICU were designed based on the HIS system and monitors in cooperation with the company from January,2015. The traditional paper-based records were totally replaced by electronic records which had been adjusted and tested for six months. Cost of time and revise were compared between traditional and electronic records ten days before the replacement. Three months later, satisfaction survey and user experiencefor the electronic records was conducted. Results The cost of time on electronic records (43 ± 11) min were much lower than traditional records(30±10) min (t=7.132, P=0.002). The revise on electronic records(20.48%, 86/420) were relatively lower than traditional records (10.24%, 43/420) (χ2=16.934, P=0.001).After using electronic nursing records the satisfaction was increased significantly from 90%(36/40) to 100%(40/40) (U=7.112, P<0.01); Nurses reflect electronic nursing records significantly better than the traditional records, according to record trend diagram of vital signs and corresponding processing, nurse managements can analysis and evaluate nursing quality, also finding original nursing records just patient information, so the nurses will be strict with their recording and processing objectively, timely. Conclusion The electronic nursing records can reflect the changes of patients' actual condition more accurately and comprehensively, and the advantage about standard, convenience and time-saving is beneficial to improve nurse work efficiency. This record system can provide the dynamical situation and evaluate the quality of nursing directly for nursing managers and doctors, also make it possible for permanent data retention.

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作者: 彭琳 [1] 韩文军 [1]
栏目名称: 基础护理
DOI: 10.3760/cma.j.issn.1672-7088.2017.26.010
发布时间: 2017-11-06
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