护理患者和技术能力在使用电子护理记录系统:一个定性研究
Cvetka Krel1, Dominika Vrbnjak1
1Faculty of Health Sciences, University of Maribor, 2000 Maribor, Slovenia.
Healthcare (Basel, Switzerland)
|January 10, 2026
概括
如果不有效使用,电子护理记录系统 (ENRS) 可以使护理变得非个性化. 发展护士的技术能力和将护理行为纳入文档是整体患者护理的关键.
科学领域:
- 护理信息学 护理信息学
- 质量健康研究 质量健康研究
- 一个有根据的理论.
背景情况:
- 电子护理记录系统 (ENRS) 旨在提高文档准确性和患者护理质量.
- 了解护士对ENRS有效性,关怀行为和技术能力的看法至关重要.
研究的目的:
- 探索护士对ENRS有效性,关怀行为和技术能力的看法.
- 研究这些因素在护理实践中的相互关系.
主要方法:
- 一个使用科尔宾和斯特劳斯接地理论方法的定性研究.
- 与斯洛文尼亚四家医院的11名护士进行半结构面试.
- 通过使用MAXQDA 2020开放,轴向和选择性编码进行数据分析.
主要成果:
- 确定的核心类别是"在以技术为重点的文档中失去关怀".
- 不充分的ENRS有效性和不良的整合导致个人化护理文件不足.
- 策略包括发展技术能力,并将护理纳入文档.
结论:
- 有效的ENRS,护士的护理行为和技术能力对于整体的患者护理文档至关重要.
- 解决ENRS的有效性和整合是维持以患者为中心的护理的关键.
相关概念视频
01:30Methods of Documentation VII: EMR
1.4K
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
1.4K
01:30Current Trends in Nursing II
3.3K
Trends in nursing are multifactorial and associated with changes in society, within the nursing profession, and in other professions. Notably, telehealth and remote nursing contribute to successful healthcare delivery for numerous patients and help reduce stress for nurses due to nursing shortages. Nurses can reach patients, monitor their conditions, and interact with them using computers, audio, visual accessories, and telephones—for example, remote patient monitoring systems. Likewise,...
3.3K
01:08Role of Communication in the Nursing Process III: Evaluation and Documentation
1.9K
A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
1.9K
01:18Guidelines and Strategies for Safe Computer Charting
2.7K
The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Maintain Confidentiality and Security:
2.7K
01:27Nursing Clinical Information System
1.2K
Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
1.2K
01:11Purpose of Health Records I
1.7K
The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:
Here's a breakdown of how health records serve these purposes:
1.7K