外科护理电子病历的设计与应用

摘要

Objective To study the methed of designing the surgical nursing electronic medical records and investigate the effect of application.Method According the nursing record form by Guangdong Provincial Clinical Nursing Writing Criterion (Specialty Version),we designed and completed the surgical nursing electronic medical records form.Result After implementation of the nursing electronic medical records,the mean time of measuring and inputting the patients’vital signs was(1.0±0.3)min and the mean time of finishing the nursing electronic medical records was 4.0±0.5 min.Conclusion Standardizing the form and content of nursing electronic medical records can improve the efficiency of routine work and the quality of nursing records.%目的：介绍外科护理电子病历设计方法，探讨其应用效果。方法根据广东省《临床护理文书规范》（专科篇）的表格式首次护理记录单（外科）设计并完成外科护理电子病历系统，并应用于临床。结果实施护理电子病历后，护士测量及录入病人生命体征时间为（1.0±0.3）min；完成护理电子病历的时间为（4.0±0.5）min。结论实施护理电子病历规范了护理记录书写形式与记录内容，提高了护理工作效率与护理记录质量。