摘要
目的实现手术护理文书信息化管理。方法手术室护士自主设计建立手术护理文书管理系统,包括手术护理记录系统、手术护理质控系统两大部分,分为手术护理文书管理、用户管理、基础信息管理等模块,通过医院内部的计算机网络完成手术护理文书的书写及质量评价。结果采用新系统后,手术护理记录单漏项、修改以及计量错误三大问题均降为0。退档数由应用前的84份下降为0,质控护士完成一份手术护理记录单质量控制的平均时间由(6.89±2.10)min下降到(1.94±0.80)min,差异有统计学意义(均P<0.01)。结论手术室实施护理文书信息化管理,使术中护理记录更规范化,不仅提高护士工作效率也提高了护理文书的质量。
Objective To realize the informational management of operating nursing documents. Methods Operating room nurses inde- pendently designed and established the operating nursing document management system including operating nursing record systems and operating nursing quality control system two parts, which were divided into several modules, such as operating nursing docu ment management, users management, basic information management and so on. Then the writing and quality evaluation of the operating nursing document were completed through the hospital＇s computer network. Results After application of the new system, the occurrence of the three major problems of leakage, modification and measurement errors of operating nursing records were ze- ro. The number of returned medical records dropped from 84 to 0, and the mean quality control time for one operating nursing re cord shortened from （6.89±2.10） min to （1.94±-0.80） rain, there were significant differences （P〈0.01 for both）. Conclusion Implementation of nursing document informational management in operating room makes intraoperative nursing records more standardized, it not only improves the job efficiency of nurses, and enhances the quality of nursing records.
出处
《护理学杂志》
CSCD
2017年第8期7-10,共4页
Journal of Nursing Science
关键词
手术室
护理文书
信息系统
质量控制
operating room
nursing documents
information system
quality control
