摘要
目的:开发护理交接班信息系统,并分析其应用效果,以提高临床护理交接班质量。方法:在组建多学科团队及制定结构化护理交接班表单的基础上,基于电子病历系统开发护理交接班信息系统,包括交班报告、历史记录查询、质控管理与统计分析四大功能模块,并在全院范围使用。比较系统应用前后护士交班准备时长、交接班记录要素完整率、交班报告信息错误率,并调查护士对系统的使用感受。结果:应用护理交接班信息系统后,护士交班准备时长较前缩短14.05 min(P<0.05),交接班记录要素完整率由93.13%提升至98.14%(P<0.05),交班报告信息错误率由8.40%降至0.06%(P<0.05),护士对该系统使用感受评价较高(各条目得分均值>4分)。结论:护理交接班信息系统的应用能够在提高临床护理工作和管理效率的前提下,提高交接班质量,提升交接班内容的正确性、完整性和规范性,进一步加强了临床交接班的闭环管理,确保了交接班工作制度有效落实。
Objective:To develop a nursing handover information system and observe its application effects to improve the quality of clinical nursing handover.Methods:Based on the formation of a multidisciplinary team and the development of a structured nursing handover form,a nursing handover information system was developed based on the electronic medical record system.The system included four main functional modules:handover report,historical record query,quality control management and statistical analysis.The system was implemented hospital-wide.Comparisons were made before and after system application regarding nurse handover preparation time,completeness of handover records,and error rate of handover report information.Additionally,nurses'feedback on the system was surveyed.Results:After the application of the nursing handover information system,the time required for nurses to prepare for handover was reduced by 14.05 minutes(P<0.05).The completeness rate of handover records has improved from 93.13%to 98.14%(P<0.05),and the error rate in handover reports has decreased from 8.40%to 0.06%(P<0.05).Nurses rated their satisfaction with the system highly(mean score for each item>4).Conclusion:The application of nursing handover information system can improve the quality of handover,improve the correctness,completeness and standardization of handover content,further strengthen the closed-loop management of clinical handover,and ensure the effective implementation of handover work system on the premise of improving clinical nursing work and management efficiency.
作者
郭月
王颖
黄丽红
尹世玉
GUO Yue;WANG Ying;HUANG Lihong;YIN Shiyu(Department of Nursing,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan,430030,China)
出处
《中国护理管理》
北大核心
2025年第1期97-100,共4页
Chinese Nursing Management
基金
华中科技大学同济医学院附属同济医院科研基金(2022D06)。
关键词
护理
交接班
信息系统
构建
护理质量
nursing
handover
information system
construction
nursing quality
