摘要
总结了电子护理病历在临床护理工作中的应用,根据临床护理工作的实际情况,研究开发了以体温单、入院评估单、护理记录(一般护理病情记录、危重护理病情记录)、特护单、护嘱单等模块为主的护理电子病历,认为电子护理病历的应用可规范护士的行为,减轻护士的作业强度,降低医疗成本,提高护士护理文书水平。
It is summarized that the clinical application of the electronic medical record on nursing,according to actual situation of clinical nursing work,a Electronic Nursing Record System are studied and developed,it is consisted of temperature sheet,admission evaluation chart, nursing record,and special nursing care record chart, nursing orders, etc, It can stadardize nurses behavior,lighten nursing working force,reduce the hospital cost and improve nursing documents.
关键词
医院信息系统
护理病历
护理管理
hospital information system
electronic nursing record system
nursing management
