2014•Unpublished venueRequires access
Clinical Application of Nursing Electronic Medical Records: Problem Analysis and Countermeasures
Liu Su-we
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Abstract
Objective To explore the problems and countermeasures in the clinical application of electronic medical records,to improve the quality of nursing electronic medical records. Method The records of hospitalized patients with more than one week of length of stay from August to December 2012 were selected,of which 500 nursing electronic medical records were randomly selected. A total of 200 questionnaire on nursing electronic medical records were distributed among clinical nurse,and all were responded. The problems in application of nursing electronic medical records were analyzed. Result According to the results of the questionnaire survey,nursing staff satisfaction rate was 90. 25%. the spot check showed that the problems were mainly inaccurate nursing records,inconsistency of the content,low authenticity,no enough objective of content,etc.,of which,the proportion of nursing record inaccurate( 45. 81%) was significantly higher than other problems( F = 6. 45,P 0. 05). Conclusion The implementation of the nursing electronic medical records can significantly improve the efficiency of nursing work and satisfaction,but there are still some problems and the insufficiency in practical application. The hospital should take active avoiding measures to improve the legal idea and electronic medical record level of nursing personnel to ensure medical record continuity,authenticity and objectivity.