电子护理文件管理实施情况分析

Solehudin Solehudin, Sancka Stella, Firyal Firyal, Nur Eni Lestari, Yeni Koto, Hari Ghanesia Istiani, Bambang Suryadi, Saiful Gunardi, Agus Purnama, Susaldi Susaldi, Weslei Daeli, Arif hidayatullah
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引用次数: 0

摘要

电子护理记录在维护患者安全方面发挥着重要作用。电子文档可以发现提高护理效率和效果的潜力。本文旨在确定电子护理文件管理的应用。本研究是学生于 2023 年 10 月 16 日至 11 月 10 日在茂物市一家医院进行护理管理阶段实践时获得的案例研究。数据收集是通过几个过程进行的,其中包括基于 5M 的电子文档管理审查、SWOT 分析和制定,以及使用规模、严重性、可管理性、护理关注度、可负担性等标准对问题的优先级进行评估,评估分为 1 - 5 分。X 室的愿景是电子化,因此有效的护士需要时间来适应技术,以开展电子化护理记录。结论是,护理记录作为记录患者护理信息的重要过程,起着至关重要的作用。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Analisis Penerapan Manajemen Dokumentasi Asuhan Keperawatan Elektronik
Electronic nursing care documentation plays an important role in maintaining patient safety. Electronic documentation can identify the potential for increasing efficiency and effectiveness in providing nursing care. The purpose of this article is to determine the application of electronic nursing care documentation management. This research is a case study obtained when students carried out the Nursing Management Stage practice at one of the hospitals in Bogor City from 16 October - 10 November 2023. Data collection was carried out through several processes which included management review of electronic documentation based on 5M, SWOT analysis and formulation and problem priorities using the criteria of magnitude, severity, manageability, nursing concern, affordability which are assessed with a score of 1 – 5. The vision of room X is electronic-based so that effective nurses need time to adapt to technology to carry out electronic-based nursing documentation. The conclusion is that documentation of nursing care plays a crucial role as an important process for recording patient care information.
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