电子报告书写对护理报告记录质量的影响。
Effect of electronic report writing on the quality of nursing report recording.
作者信息
Heidarizadeh Khadijeh, Rassouli Maryam, Manoochehri Houman, Tafreshi Mansoureh Zagheri, Ghorbanpour Reza Kashef
机构信息
PhD Candidate, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
PhD, Associate Professor, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
出版信息
Electron Physician. 2017 Oct 25;9(10):5439-5445. doi: 10.19082/5439. eCollection 2017 Oct.
BACKGROUND AND AIM
Recording performed nursery actions is one of the main chores of nurses. The findings have shown that recorded reports are not qualitatively valid. Since electronic reports can be regarded as a base to write reports, this study aims at determining the effect of utilizing electronic nursing reports on the quality of the records.
METHODS
This quasi-experimental study was conducted with the aim of applying an electronic system of nursing recording in the heart department of Shahid Rahimi Medical Center, Lorestan University of Medical Science. The samples were nursing reports on the hospitalized patients in the heart department, the basis of complete enumeration (census) during the fall of 2014. The subjects were sixteen employed nurses. To do the study, the software of nursing records was set based on the Clinical Care Classification system (CCC). The research's tool was the checklist of the Standards of Nursing Documentation.
RESULTS
The findings indicated that before and after the intervention, the amount of reports' adaption with the written standards, respectively, was (21.8%) and (71.3%), and the most complete recording was medicine status (58%) and (100%). The worst complete recording before the intervention, acute changes was (99.1%) and nursing processes was (78%) and after, the medicine status, intake and output status and patient's education (100%); while the nursing report structure was regarded in all cases (100%). The results showed that there is a significant difference in the quality of reporting before and after using CCC (p<0.001).
CONCLUSIONS
Since the necessary parameters for recording a standard report do exist in electronic reporting (CCC), from one point, nurses are reminded to record the necessary parts and from the other point, the system does not allow the user to shut it down unless the necessary parameters are recorded. For this reason, the quality of recorded reports with electronic reporting improves.
背景与目的
记录已执行的护理操作是护士的主要工作之一。研究结果表明，记录报告在质量上并不有效。由于电子报告可被视为撰写报告的基础，本研究旨在确定使用电子护理报告对记录质量的影响。
方法
本准实验研究旨在将电子护理记录系统应用于洛雷斯坦医科大学沙希德·拉希米医疗中心心脏科。样本为心脏科住院患者的护理报告，以2014年秋季的完全枚举（普查）为基础。研究对象为16名在职护士。为开展本研究，护理记录软件基于临床护理分类系统（CCC）进行设置。研究工具为护理文件标准检查表。
结果
研究结果表明，干预前后，报告符合书面标准的比例分别为（21.8%）和（71.3%），记录最完整的是用药情况（58%）和（100%）。干预前记录最不完整的急性变化为（99.1%），护理流程为（78%），干预后用药情况、出入量情况和患者教育为（100%）；而护理报告结构在所有情况下均为（100%）。结果显示，使用CCC前后报告质量存在显著差异（p<0.001）。
结论
由于电子报告（CCC）中存在记录标准报告所需的参数，一方面，提醒护士记录必要部分；另一方面，系统不允许用户关闭，除非记录了必要参数。因此，电子报告的记录质量得以提高。
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