护理电子病历临床应用问题调查分析及对策

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1、护理电子病历临床应用问题调查分析及对策护理电子病历临床应用问题调查分析及对策■刘素温黄先涛南茹【摘要】目的探讨护理电子病历临床应用中存在的问题及对策，提高护理电子病历质量。方法选择2012年8月~12月住院1周以上患者病历,采用随机抽样法抽取500份护理电子病历，同时向临床一线护士发放调查问卷200份，收回200份。分析护理电子病历应用中存在的问题。结果调查问卷结果显示,护理人员对护理电子病历的应用满意率为90.25%;抽查病历结果显示，存在问题主要是护理记录表达不准确、记录内容不连贯、真实性降低、内容不客观等,其中护理记录表

2、达不准确比例（45.81%）明显高于其它问题，差异具有统计学意义（F二6.45,Pv0.05L结论护理电子病历的实施能够显著提高护理人员工作效率和满意度，但在实际应用中仍存在问题和不足z医院需采取积极的应对措施提高护理人员法制观念和护理电子病历质量，保证病历连贯性、真实性和客观性。关键词护理电子病历；临床；应用ClinicalApplicationofNursingElectronicMedicalRecords:ProblemAnalysisandCountermeasures/LIUSuwen/HUANGXiantaozN

3、ANRu.//ChineseHealthQualityManagementz2014z21⑸:55・57AbstractObjectiveToexploretheproblemsandcountermeasuresintheclinicalapplicationofelectronicmedicalrecorcls,toirnprovethequalityofnursingelectronicmedicalrecords.MethodTherecordsofhospitalizedpatientswithmorethanone

4、weekoflengthofstayfromAugusttoDecember2012wereselected,ofwhich50Onursingelectronicmedicalrecordswererandomlyselected.Atotalof200questionnaireonnursingelectronicmedicalrecordsweredistributedamongclinicalnurse,andallwereresponded.Theproblemsinapplicationofnursingelect

5、ronicmedicalrecordswereanalyzed.ResultAccordingtotheresultsofthequestiormairesurveyznursingstaffsatisfactionratewas90.25%.thespotcheckshowedthattheproblemsweremainlyinaccuratenursingrecords」neonsistencyofthecontentjowauthenticity,noenoughobjectiveofcontent,etc.zofwh

6、ichztheproportionofnursingrecordinaccurate(45.81%)wassignificantlyhigherthanotherproblems(F=6.45zP0.05).ConclusionTheimplementationofthenursingelectronicmedicalrecordscansignificantlyimprovetheefficiencyofnursingworkandsatisfaction,buttherearestillsomeproblemsandthe

7、insufficiencyinpracticalapplication.Thehospitalshouldtakeactiveavoidingmeasurestoimprovethelegalideaandelectronicmedicalrecordlevelofnursingpersonneltoensuremedicalrecordcontinuity,authenticityandobjectivity.KeywordsNursingElectronicMedicalRecords;Clinical;Applicati

8、onFirstauthoracute;saddressFirstAffiliatedHospitalzNorthInstituteofHebeizZhangjiakou,Hebei,075000,China随着医学技术和计算机技术的不断发展，电子病历已广泛应用于临床实践[1L