School of Language and Literature, Linnaeus University, Kalmar, Sweden.
J Adv Nurs. 2012 Mar;68(3):667-76. doi: 10.1111/j.1365-2648.2011.05786.x. Epub 2011 Jul 22.
The overall aim of this study was to explore nurses' perceptions of using an electronic patient record in everyday practice, in general ward settings. This paper reports on the patient safety aspects revealed in the study.
Electronic patient records are widely used and becoming the main method of nursing documentation. Emerging evidence suggests that they fail to capture the essence of clinical practice and support the most frequent end-users: nurses. The impact of using electronic patient records in general ward settings is under-explored.
In 2008, focus group interviews were conducted with 21 Registered Nurses. This was a qualitative study and the data were analysed by content analysis. At the time of data collection, the electronic patient record system had been in use for approximately 1 year.
The findings related to patient safety were clustered in one main category: 'documentation in everyday practise'. There were three sub-categories: vital signs, overview and medication module. Nurses reported that the electronic patient record did not support nursing practice when documenting crucial patient information, such as vital signs.
Efforts should be made to include the views of nurses when designing an electronic patient record to ensure it suits the needs of nursing practice and supports patient safety. Essential patient information needs to be easily accessible and give support for decision-making.
本研究的总体目的是探讨护士在普通病房环境中日常实践中使用电子病历的看法。本文报告了研究中揭示的患者安全方面的内容。
电子病历已被广泛使用，并成为护理记录的主要方法。新出现的证据表明，它们未能捕捉到临床实践的本质，也无法满足最常使用的用户：护士的需求。在普通病房环境中使用电子病历的影响尚未得到充分探索。
2008 年，对 21 名注册护士进行了焦点小组访谈。这是一项定性研究，采用内容分析法分析数据。在数据收集时，电子病历系统已经使用了大约 1 年。
与患者安全相关的发现集中在一个主要类别中：“日常实践中的文档记录”。有三个子类别：生命体征、概述和用药模块。护士报告说，在记录关键患者信息（如生命体征）时，电子病历并不能支持护理实践。
在设计电子病历时，应努力纳入护士的意见，以确保其符合护理实践的需求并支持患者安全。基本患者信息需要易于访问，并为决策提供支持。
