骨科护理结构化电子病历分析与基于国际护理实践分类的对照研究(1)
【摘要】 目的：分析護理结构化电子病历及与基于国际护理实践分类(international classification of nursing practice，ICNP)的对比。方法：选取2014年6月-2015年6月本院骨科住院患者病历400份纳为传统书写模块组，采用自由书写方式；选取2015年8月-2016年8月的病历400份纳为结构化模块组，采用结构化模块书写方式。比较两组病历的记录词汇与ICNP2.0对比情况；于2016年9月选取本院骨科护理人员57名发放调查问卷，调查对两种病历书写方式的认可情况。结果：结构化模块组完全匹配为58.25%，高于传统书写模块组的44.75%(P<0.05)；结构化模块组与ICNP2.0对比部分匹配24.00%，低于传统书写模块组的32.50%(P<0.05)；结构化模块组与ICNP2.0对比不匹配17.75%，低于传统书写模块组的22.75%，比较差异无统计学意义(P>0.05)。自由书写的书写灵活性、主观性均优于结构化模块书写(P<0.05)；结构化模块书写的语言记录准确率、记录时间、病历完整性、医学术语标准化统一及评估与记录全面性均优于自由书写(P<0.05)；两种书写方式的病历文本复制度比较，差异无统计学意义(P>0.05)；57名护理人员中有64.91%倾向于使用结构化模块书写。结论：骨科护理病历采用结构化模块书写模式，能够缩短记录时间，提高效率，且评估和记录更全面，有利于提升护理质量，提高医疗信息的利用率。
, 百拇医药
【关键词】 骨科； 护理电子病历； 结构化分析； ICNP
Analysis of Structured Electronic Medical Records in Department of Orthopedics Nursing and A Comparative Study Based on International Classification of Nursing Practice/WEI Longli，SUN Qifeng，YANG Shuai.//Medical Innovation of China，2018，15(01)：092-095
【Abstract】 Objective：To analyze the structured electronic medical records and comparison based on international classification of nursing practice(ICNP).Method：A total of 400 medical records in department of orthopedics of our hospital from June 2014 to June 2015 were selected as the traditional writing module group，the free writing method was adopted，and 400 medical records from August 2015 to August 2016 were selected as the structured module group， the structured module writing mode was adopted.The comparison of the recorded vocabulary of two groups with the ICNP2.0 were compared，in September 2016，57 nurses from department of orthopedics in our hospital were selected to issue a questionnaire to investigate the approval of the writing methods of two kinds of medical records.Result：The fully matched of structured modular group was 58.25%，which was higher than 44.75% of traditional writing module group(P<0.05)，the partially matched of structured modular group was 24.00%，which was lower than 32.50% of traditional writing module group(P<0.05)，the mismatching of structured modular group was 17.75%，which was lower than 22.75% of traditional writing module group，but the difference was not statistically significant(P>0.05).The writing flexibility and subjectivity of free writing were better than that of structured module writing(P<0.05)，the accuracy rate，record time，medical records integrity，standardization of medical terms，evaluation and record comprehensiveness of structured modules were better than those of free writing (P<0.05)，the copy degree of the medical records in the two ways of writing were compared，the difference was not statistically significant(P>0.05)，and 64.91% of the 57 nurses tended to write with structured modules.Conclusion：The nursing records in the department of orthopedics are written by the structured module，can shorten the time of recording，improve efficiency，and make the evaluation and record more comprehensive，which is beneficial to improve the quality of nursing and improve the utilization rate of medical information., 百拇医药(韦隆莉 孙其凤 杨帅)
, 百拇医药
【关键词】 骨科； 护理电子病历； 结构化分析； ICNP
Analysis of Structured Electronic Medical Records in Department of Orthopedics Nursing and A Comparative Study Based on International Classification of Nursing Practice/WEI Longli，SUN Qifeng，YANG Shuai.//Medical Innovation of China，2018，15(01)：092-095
【Abstract】 Objective：To analyze the structured electronic medical records and comparison based on international classification of nursing practice(ICNP).Method：A total of 400 medical records in department of orthopedics of our hospital from June 2014 to June 2015 were selected as the traditional writing module group，the free writing method was adopted，and 400 medical records from August 2015 to August 2016 were selected as the structured module group， the structured module writing mode was adopted.The comparison of the recorded vocabulary of two groups with the ICNP2.0 were compared，in September 2016，57 nurses from department of orthopedics in our hospital were selected to issue a questionnaire to investigate the approval of the writing methods of two kinds of medical records.Result：The fully matched of structured modular group was 58.25%，which was higher than 44.75% of traditional writing module group(P<0.05)，the partially matched of structured modular group was 24.00%，which was lower than 32.50% of traditional writing module group(P<0.05)，the mismatching of structured modular group was 17.75%，which was lower than 22.75% of traditional writing module group，but the difference was not statistically significant(P>0.05).The writing flexibility and subjectivity of free writing were better than that of structured module writing(P<0.05)，the accuracy rate，record time，medical records integrity，standardization of medical terms，evaluation and record comprehensiveness of structured modules were better than those of free writing (P<0.05)，the copy degree of the medical records in the two ways of writing were compared，the difference was not statistically significant(P>0.05)，and 64.91% of the 57 nurses tended to write with structured modules.Conclusion：The nursing records in the department of orthopedics are written by the structured module，can shorten the time of recording，improve efficiency，and make the evaluation and record more comprehensive，which is beneficial to improve the quality of nursing and improve the utilization rate of medical information., 百拇医药(韦隆莉 孙其凤 杨帅)