摘要
目的进一步规范护理病历的书写格式,提高书写的质量和效率,使护理病历更加规范化、科学化、简捷化。方法根据卫生部《病历书写基本规范》、《2010年"优质护理服务示范工程"活动方案》简化护理文书的要求,按照护理工作流程,利用嘉和电子病历系统,开发研制了表格式护理电子病历。结果在优质护理服务病房使用表格式护理电子病历,明显缩短了护士的书写时间,增加了护士直接服务患者的时间。结论表格式护理电子病历以书写快捷、格式规范、记录清晰等特点,在优质护理服务中充分体现了它的优势,明显提高了护理病历书写的质量和效率,有效实现了护理文件书写网络化管理。
Objective： To standardize writing format of nursing records and improve writing quality and efficiency so as to create standard, scientific and concise nursing records. Methods： Tabular electronic nursing record was developed based on Goodwill electronic medical record system by following nursing procedures and complying with requirements of simplifying nursing records regulated by Medical Informed Consent and Planning for 2010 ＂High-quality Nursing Service Demonstration Project＂ issued by the Ministry of Health. Results： Application of tabular electronic nursing records in high-quality nursing service wards could significantly reduce writing time and increase service time of nurses. Conclusion： Tabular electronic nursing record gives full display to its advantages of fast writing, format specification and clear record in high-quality nursing services, improves recording quality and efficiency and achieves online management of nursing records.
出处
《医院管理论坛》
2013年第5期46-48,共3页
Hospital Management Forum
关键词
表格式
护理电子病历
优质护理服务
tabular
electronic nursing record
high-quality nursing service
