Moody L, Snyder P E
Nurs Econ. 1995 Jan-Feb;13(1):24-31.
Nursing documentation is an important component of clinical nursing practice. It is estimated that 15%-20% of work time is spent documenting patient information and that documentation is the most common cause for overtime. An evaluation of hospital staff satisfaction with a recently implemented documentation system showed that 70% are satisfied with the new system; 75% agree that consistency of nursing documentation has improved; 72% agree that availability of records has improved; 78% agree the placement of the nursing documentation at the point of service facilitates location of data; and 65% agree there has been a decrease in the number of forms they have to review in order to locate nursing information.
护理记录是临床护理实践的重要组成部分。据估计，15% - 20%的工作时间用于记录患者信息，且记录工作是加班的最常见原因。一项对医院工作人员对最近实施的记录系统满意度的评估显示，70%的人对新系统满意；75%的人认为护理记录的一致性有所提高；72%的人认为记录的可获取性有所改善；78%的人认为护理记录在服务点的放置便于数据查找；65%的人认为为查找护理信息而必须查看的表格数量有所减少。
