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电子护理文档记录在保障患者安全、提高护理质量和护理记录方面的作用:一项系统综述。

Electronic nursing documentation for patient safety, quality of nursing care, and documentation: a systematic review .

机构信息

Department of Nursing, Universitas Airlangga, Surabaya, Indonesia.

Department of Medical-Surgical Nursing, King Khalid University, Abha, Saudi Arabia.

出版信息

J Pak Med Assoc. 2024 Sep;74(9):1669-1677. doi: 10.47391/JPMA.9996.

Abstract

OBJECTIVE

To evaluate the impact of electronic nursing documentation on patient safety, quality of nursing care and documentation.

METHODS

The systematic review was conducted in December 2022, and comprised a comprehensive search on Scopus, ScienceDirect, ProQuest, PubMed, Cumulative Index to Nursing and Allied Health Literature, Sage Journals and Google Scholar databases for English-language human studies published between 2018 and 2022. The key words used in the search included "Nursing", "care", "documentation", "record", "electronic", "process" and "health services". The risk of bias was assessed using Strengthening the Reporting of Observational Studies in Epidemiology tool.

RESULTS

Of the 469 items initially identified, 15(3.2%) were analysed in detail, indicating a positive influence of electronic nursing documentation on patient safety, care quality, and documentation. However, shortcomings were observed in the development of electronic nursing documentation for optimal effectiveness.

CONCLUSION

Electronic nursing documentation significantly enhanced patient safety, care quality and documentation. To facilitate its integration into clinical settings, a standardised and logically structured electronic nursing documentation system is essential.

摘要

目的

评估电子护理记录对患者安全、护理质量和记录的影响。

方法

系统评价于 2022 年 12 月进行,在 Scopus、ScienceDirect、ProQuest、PubMed、Cumulative Index to Nursing and Allied Health Literature、Sage Journals 和 Google Scholar 数据库中对 2018 年至 2022 年期间发表的英语人类研究进行了全面搜索。搜索中使用的关键词包括“护理”、“护理”、“记录”、“记录”、“电子”、“流程”和“医疗服务”。使用流行病学观察研究报告强化工具评估偏倚风险。

结果

最初确定的 469 项中,有 15 项(3.2%)进行了详细分析,表明电子护理记录对患者安全、护理质量和记录有积极影响。然而,在开发电子护理记录以实现最佳效果方面存在不足。

结论

电子护理记录显著提高了患者的安全性、护理质量和记录。为了促进其在临床环境中的整合,需要一个标准化和逻辑结构的电子护理记录系统。

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