Design and application of integrated and structural electronic nursing records in SICU / 中国实用护理杂志

ABSTRACT

Objective To evaluate the design and effectiveness of electronic nursing records. Methods The integrated and structural electronic nursing records of SICU were designed based on the HIS system and monitors in cooperation with the company from January,2015. The traditional paper-based records were totally replaced by electronic records which had been adjusted and tested for six months. Cost of time and revise were compared between traditional and electronic records ten days before the replacement. Three months later, satisfaction survey and user experiencefor the electronic records was conducted. Results The cost of time on electronic records (43 ± 11) min were much lower than traditional records(30±10) min (t=7.132, P=0.002). The revise on electronic records(20.48%, 86/420) were relatively lower than traditional records (10.24%, 43/420) (χ2=16.934, P=0.001).After using electronic nursing records the satisfaction was increased significantly from 90%(36/40) to 100%(40/40) (U=7.112, P<0.01); Nurses reflect electronic nursing records significantly better than the traditional records, according to record trend diagram of vital signs and corresponding processing, nurse managements can analysis and evaluate nursing quality, also finding original nursing records just patient information, so the nurses will be strict with their recording and processing objectively, timely. Conclusion The electronic nursing records can reflect the changes of patients' actual condition more accurately and comprehensively, and the advantage about standard, convenience and time-saving is beneficial to improve nurse work efficiency. This record system can provide the dynamical situation and evaluate the quality of nursing directly for nursing managers and doctors, also make it possible for permanent data retention.