| 摘要: |
| ［摘要］ 目的 探讨护理文书电子模块在提高护理工作效率、护理服务质量和护理管理中的应用效果。方法 根据国家卫计委颁发的《护理文书书写规范》的相关要求和内容，结合医院各科护理人员构成、工作性质和专业特点，设计开发全院共性和各科室（病区）个性化的护理文书电子模块，2016-01开始开发，并在3个科室（病区）试点应用；2016-06在全院各科室（病区）推广应用；2016-12总结和分析比较应用电子模块前后的护理工作效率和护理服务质量。结果 应用护理文书电子模块后，护理人员护理文书书写的工作效率，护理文书书写的质量和相关人群对护理工作的满意度均较应用前有明显的提高，差异均有统计学意义（P<0.01）。结论 护理文书电子模块内容和格式完整、标准、科学、规范，使用方便、快捷、实用，能有效提高护理文书书写工作效率和护理服务质量。 |
| 关键词: 护理文书 电子模块 效果评价 |
| DOI：10.3969/j.issn.1674-3806.2017.07.07 |
| 分类号:R 741 |
| 基金项目:广西卫计委科研课题（编号：Z2016786） |
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| Research on the development and application of electronic module of nursing documents |
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QIN Ai-fang, WU Jin-ju, QIN Zhao-ju, et al.
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Department of Nursing, the Third People′s Hospital of Hechi City, Guangxi 547000, China
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| Abstract: |
| ［Abstract］ Objective To explore the effect of electronic module of nursing documents on improving nursing work efficiency and nursing service quality and nursing management. Methods According to the requirements and the relevant content in “The Nursing Documents Writing Standards” issued by the National Health Planning Commission, combined with the condition of nursing staff, the nature of work and professional characteristics, the electronic module of nursing documents was designed and developed and the electronic module of nursing documents can be used in the whole hospital and the various specialized departments(wards). The electronic module of nursing documents was developed in January 2016 and was first tested in 3 departments, then popularized in all departments of the hospital in June 2016. The nursing work efficiency and nursing service quality were summarized and analyzed before and after the application of electronic module.Results After the application of the electronic module, the work efficiency and quality of nursing documents writing in the nursing staff were improved, and the relevant people′s satisfaction to nursing work was higher than that before the application with a statistical significance(P<0.01).Conclusion The contents and format of electronic module of nursing documents are complete, standard, scientific and normative. The electronic module of nursing documents has the advantages of convenient, quick and practical application, and can effectively improve the writing work efficiency and nursing service quality. |
| Key words: Nursing documents Electronic module Effect evaluation |
