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抽查作者所在医院350份护理电子病历,按护理记录评价标准进行检查。护理电子病历合格率最低的是病情护理记录单(93.7%),最高是入院评估单(96.6%)。存在主要问题是护理记录有大片复制粘贴现象,未突出重点;护士对电子病历的应用程序不熟悉、汉字输入速度慢;病历质控缺乏力度。应提高护士法律意识、工作责任心及书写水平,强化电子病历应用程序和输入法培训,加强电子病历监督,以提高护理电子病历书写质量。
Check the author’s hospital 350 nursing electronic medical records, according to nursing records evaluation criteria for inspection. Care electronic medical record the lowest pass rate is the condition care record (93.7%), the highest admission assessment (96.6%). The main problem is that nursing records have a large number of copy and paste phenomenon, not highlight the focus; nurses are not familiar with the application of electronic medical records, Chinese input speed is slow; lack of strength of quality control of medical records. Nurses should be more legal awareness, work responsibility and writing skills, strengthen the application of electronic medical records and input method training, strengthen electronic medical records supervision, in order to improve the quality of nursing electronic medical records.