Designing and application of surgical nursing electronic medical records / 现代临床护理

ABSTRACT

Objective To study the methed of designing the surgical nursing electronic medical records and investigate the effect of application.Method According the nursing record form by Guangdong Provincial Clinical Nursing Writing Criterion (Specialty Version),we designed and completed the surgical nursing electronic medical records form.Result After implementation of the nursing electronic medical records,the mean time of measuring and inputting the patients’vital signs was(1.0±0.3)min and the mean time of finishing the nursing electronic medical records was 4.0±0.5 min.Conclusion Standardizing the form and content of nursing electronic medical records can improve the efficiency of routine work and the quality of nursing records.