国际医药卫生导报2012，Vol.18Issue(23)：3394-3396,3.DOI:10.3760/cma.j.issn.1007-1245.2012.23.004
电子护理病历与手工护理病历优势比较的研究
Research on electronic nursing records versus manual nursing records
摘要
Abstract
Objective To explore the different way of writing between electronic nursing records and manual nursing records and find out the difference between those two.Methods A clinical survey was conducted.2031 pieces of manual nursing records created between August 1 st and August 30th,2010 were used as group A,with an average hospitalization of 67.7 patients/day.2132 pieces of electronic nursing records created between August 1st and August 30th,2012 were used as group B,with an average hospitalization of 71 patients/day.Body temperature chart,medical order,and speed and quality of nursing record writing were investigated.The format of electronic nursing records was the same as that of manual nursing records.Results Group B spent much less time in body temperature chart drawing ([14.97 ± 0.46]batches/d [min],[0.21 ± 0.00] min/piece vs.[82.93 ± 1.92] batches/d [min],[1.23 ± 0.02] min/piece;t=70.23,120.82,P＜ 0.05),conduction of medical order ([80.67 ± 3.05] batches/d [min],[1.13 ± 0.04]min/piece vs.[187.93 ± 5.89] batches/d [min],[2.78 ± 0.05] min/piece; t=33.08,54.72,P＜ 0.05),and nursing record writing ([2.85 ± 0.21] min/piece,[1.72 ± 0.23] min/piece vs.[10.10 ± 0.47]min/piece,[4.99 ± 0.54] min/piece;t=28.24,11.13,P＜ 0.05) than group A.Conclusions Electronic medical records alter the process and methods of nursing care and improve work efficiency and quality,which is easier to retrieve,consult,and manage the nursing records.关键词
手工护理病历/电子护理病历/工作效率Key words
Electronic nursing record/Manual nursing record/Work efficiency引用本文复制引用
李惠卿,赵德生,汤舜銮,林瑄,洪蝶玫..电子护理病历与手工护理病历优势比较的研究[J].国际医药卫生导报,2012,18(23):3394-3396,3.基金项目
汕头市重点科技计划项目立项课题(汕府科[2011]46号42-39) （汕府科[2011]46号42-39）
