Ju Jae-Kyun, Jeong Hye-Won
Department of Surgery, Chonnam National University Hospital, Gwangju 61469, Republic of Korea.
Department of Surgery, Chonnam National University Medical School, Gwangju 61469, Republic of Korea.
Healthcare (Basel). 2025 Feb 8;13(4):365. doi: 10.3390/healthcare13040365.
: New nurses often face challenges in adapting to clinical environments, particularly in mastering electronic medical record (EMR) systems, which are critical for effective patient care and communication. This study aimed to evaluate the effectiveness of a practice-oriented EMR education program designed to improve new nurses' EMR competencies. : A quasi-experimental pretest-post-test design with a non-equivalent control group was employed. Fifty-four new nurses employed for less than a year participated, with 25 in the intervention group and 29 in the comparison group. The intervention group underwent five weekly sessions focused on core EMR tasks, including admission nursing, operation/procedure documentation, patient transfer/discharge, night duties, and SBAR handovers. The program, led by clinical nurse educators, incorporated lectures, practical exercises, and Q&A sessions. EMR competencies were assessed using a validated 5-point Likert scale. : The intervention group showed significant improvements across all assessed domains, with post-program scores significantly higher than those of the comparison group. The most notable improvements were in operation/procedure documentation and patient transfer/discharge tasks. The comparison group's gains were limited, likely reflecting natural skill acquisition through clinical experience. : The practice-oriented EMR education program effectively enhanced new nurses' EMR competencies. The program's structured approach, which combined theoretical instruction with extensive hands-on practice and department-specific adaptations, proved particularly effective in improving complex documentation tasks. The integration of comprehensive EMR training into nursing curricula and the expansion of such programs to other institutions are recommended for broader implementation.
新护士在适应临床环境方面常常面临挑战,尤其是在掌握电子病历(EMR)系统方面,而电子病历系统对于有效的患者护理和沟通至关重要。本研究旨在评估一项以实践为导向的电子病历教育项目的有效性,该项目旨在提高新护士的电子病历能力。
采用了带有非对等对照组的准实验前测-后测设计。54名入职不到一年的新护士参与其中,干预组25人,对照组29人。干预组接受了为期五周的课程,重点是电子病历的核心任务,包括入院护理、手术/操作记录、患者转科/出院、夜班工作以及SBAR交班。该项目由临床护士教育工作者主导,包括讲座、实践练习和问答环节。使用经过验证的5点李克特量表评估电子病历能力。
干预组在所有评估领域均有显著改善,项目后的得分显著高于对照组。最显著的改善在于手术/操作记录和患者转科/出院任务。对照组的进步有限,这可能反映了通过临床经验自然获得的技能。
以实践为导向的电子病历教育项目有效地提高了新护士电子病历能力。该项目的结构化方法,即将理论教学与广泛的实践操作以及针对特定科室的调整相结合,在改善复杂的记录任务方面被证明特别有效。建议将全面的电子病历培训纳入护理课程,并将此类项目扩展到其他机构以实现更广泛的实施。