现代临床护理
現代臨床護理
현대림상호리
MODERN CLINICAL NURSING
2014年
8期
76-78
,共3页
袁志敏%蒋莉%欧红桃%黄丽兴%苏小聪%钟宁
袁誌敏%蔣莉%歐紅桃%黃麗興%囌小聰%鐘寧
원지민%장리%구홍도%황려흥%소소총%종저
计算机化%电子病历%护理记录
計算機化%電子病歷%護理記錄
계산궤화%전자병력%호리기록
computerized%electronic medical records%nursing records
目的:介绍外科护理电子病历设计方法,探讨其应用效果。方法根据广东省《临床护理文书规范》(专科篇)的表格式首次护理记录单(外科)设计并完成外科护理电子病历系统,并应用于临床。结果实施护理电子病历后,护士测量及录入病人生命体征时间为(1.0±0.3)min;完成护理电子病历的时间为(4.0±0.5)min。结论实施护理电子病历规范了护理记录书写形式与记录内容,提高了护理工作效率与护理记录质量。
目的:介紹外科護理電子病歷設計方法,探討其應用效果。方法根據廣東省《臨床護理文書規範》(專科篇)的錶格式首次護理記錄單(外科)設計併完成外科護理電子病歷繫統,併應用于臨床。結果實施護理電子病歷後,護士測量及錄入病人生命體徵時間為(1.0±0.3)min;完成護理電子病歷的時間為(4.0±0.5)min。結論實施護理電子病歷規範瞭護理記錄書寫形式與記錄內容,提高瞭護理工作效率與護理記錄質量。
목적:개소외과호리전자병력설계방법,탐토기응용효과。방법근거광동성《림상호리문서규범》(전과편)적표격식수차호리기록단(외과)설계병완성외과호리전자병력계통,병응용우림상。결과실시호리전자병력후,호사측량급록입병인생명체정시간위(1.0±0.3)min;완성호리전자병력적시간위(4.0±0.5)min。결론실시호리전자병력규범료호리기록서사형식여기록내용,제고료호리공작효솔여호리기록질량。
Objective To study the methed of designing the surgical nursing electronic medical records and investigate the effect of application.Method According the nursing record form by Guangdong Provincial Clinical Nursing Writing Criterion (Specialty Version),we designed and completed the surgical nursing electronic medical records form.Result After implementation of the nursing electronic medical records,the mean time of measuring and inputting the patients’vital signs was(1.0±0.3)min and the mean time of finishing the nursing electronic medical records was 4.0±0.5 min.Conclusion Standardizing the form and content of nursing electronic medical records can improve the efficiency of routine work and the quality of nursing records.