Objective: To improve recording efficiency and quality of the intensive care observation through information technology and construction of system intellectualization.Methods: We determined developing needs and completed system optimization. Results:We developed and improved eight projects, including tracking and recording important and typical data and "a key type" recording system of nursing intervention etc. We had put the system on trial for half a year and the results showed that it could reduce primary nurses' recording time 70 minutes in ICU and nurses' approval rates were 9.2 by visual analogue scale method. Conclusion: This model could reduce the recording time and working burden of primary nurses and improve the quality of critical care observation. The primary nurse could have more time and energy to provide direct nursing time for the patients and provide protection for excellent nursing service.%目的:通过信息技术,完善系统智能化建设,有效提高重症护理观察记录的效率和质量.方法:确定研究建立的需求,完成系统优化.结果:完成对重要、典型数据的跟踪、记录;护理措施"一键式"录入等8个项目的建立、改进;试用半年,ICU责任护士减少记录时间约70min;用视觉模拟评分法进行评价,护士认可度达9.2分.结论:减少责任护士的记录时间,减轻护士的工作压力,改善重症护理观察记录的质量.让护士有更多的时间和精力,为病人提供直接护理,为病人得到优质护理服务提供保证.
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