床边护士记录实践:在病人床边还是不在病人床边?

IF 1.3 4区 医学 Q4 COMPUTER SCIENCE, INTERDISCIPLINARY APPLICATIONS
Holly E Gauthier-Wetzel
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引用次数: 0

摘要

高质量的护理要求提供者准确及时地记录。医院已在住院病人、门诊病人和长期护理设施中使用技术来记录病人护理。研究表明,通过减少医疗差错,自从实施和使用电子记录病人护理以来,我们的社区健康和福利在世界范围内得到了改善。尽管电子文档已被证明是对病人记录保存的一种改进,但在什么地方进行最有效的文档记录仍然是一个问题。在开展本项目的地点,只有重症监护室在病房内配备了用于记录的电脑。本项目评估了床旁护士对记录工作效率的看法,并对记录地点进行了评估。可以选择在病人床边、轮式工作站或护理站。在位于美国东北部地区的一家退伍军人事务医疗中心的外科和内科/外科护理单元的病人房间安装电脑之前和之后,都对床边护理人员进行了调查。这个项目的结果并没有最终回答所提出的问题:"护士们认为哪种输入方式记录病人护理更有效率,是在病房的电脑上,还是在护士站,或是在带轮子的工作站上?应探索创新策略,为病房内用于记录病人护理情况的计算机开发用户友好型设计。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Bedside Nurse Documentation Practices: At the Patient Bedside or Not?

High-quality care requires precise and timely provider documentation. Hospitals have used technology to document patient care within both the inpatient and outpatient areas and long-term care facilities. Research has demonstrated, by revealing a reduction in medical errors, that there has been a worldwide improvement in our community health and welfare since the implementation and utilization of documenting patient care electronically. Although electronic documentation has proven to be an improvement in patient record keeping, the most efficient location in which this documentation is to occur remains a question. At the location where this project took place, only the ICU had computers within the patient rooms for documentation purposes. This project evaluated bedside nurses' opinions related to the efficiency of documentation practices compounded by the location where documentation took place. The options were at the patient's bedside, on a workstation on wheels, or at the nursing station. Surveys were provided to bedside nursing staff both before and after computers were installed in patients' rooms in surgical and medical/surgical nursing units at a Veteran Affairs Medical Center located in the Northeastern region of the United States. The results of this project inconclusively answer the question posed: "Which mode of entry do nurses feel is more efficient to document patient care, on a computer in the patient room, at the nurses' station, or on a workstation on wheels?" Innovative strategies should be explored to develop a user-friendly design for computers located within the patient rooms for patient documentation.

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来源期刊
Cin-Computers Informatics Nursing
Cin-Computers Informatics Nursing 工程技术-护理
CiteScore
2.00
自引率
15.40%
发文量
248
审稿时长
6-12 weeks
期刊介绍: For over 30 years, CIN: Computers, Informatics, Nursing has been at the interface of the science of information and the art of nursing, publishing articles on the latest developments in nursing informatics, research, education and administrative of health information technology. CIN connects you with colleagues as they share knowledge on implementation of electronic health records systems, design decision-support systems, incorporate evidence-based healthcare in practice, explore point-of-care computing in practice and education, and conceptually integrate nursing languages and standard data sets. Continuing education contact hours are available in every issue.
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