Based on Basic Criteria of Medical Records issued by Ministry of Health and specialized diseases nursing quality standards,the electronic nursing records system of specialized hospital was upgraded and expanded in functions. Integrated with the idea of quality control,a real-time quality and safety control system for electronic nursing records was developed and applied in clinical practice. As a result,the problem about incomplete and not timely medical records was resolved,and the quality of nursing was promoted.%遵循卫生部颁发的<病历书写基本规范>和专科疾病护理质量标准,对专科医院护理电子病历进行系统升级和功能拓展,在系统中触入质I监控理念,探索开发了护理电子病历质量实时监控系统.临床应用后,较好地解决了病历记录内容缺项和不及时记录的问题,与应用前1年相比,全院各病区护理文书质量检查的合格率由90%上升到98%,护理不良事件的发生率降低了15%,护理质量明显提高.
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