【摘要】 目的规范护士工作站的使用,减少护理缺陷,提高工作效率。方法将2004年10月~2005年5月的《错误医疗信息更正单》按科室、错误内容、错误原因进行统计分析。结果医疗信息错误主要发生在护理工作较为繁忙的科室,其中74.64%是费用错误,涉及药品、材料、医疗护理服务、手术室计费等多个方面。非费用错误占25.36%,主要是医嘱执行时间错误。错误原因主要是手误、手术方案变更、计算机默认值与实际发生值不符等。结论通过统计分析,找到信息管理薄弱点,并提出相应的管理对策。更多还原

【Abstract】 Objective To regulate the use of nursing station in order to reduce nursing defects and improve working efficiency.Method All the “correcting bill of wrong medical information” from October 2004 to May 2005 were analyzed according to different departments,contents of errors and reasons.Results Wrong medical information was mainly occurred in the departments with overload nursing works.The main wrong information occurred in the medical charge,such as drugs,medical materials,medical service and operation fees,which accounted for 74.64%.The other wrong medical information was about the time of treatment.The main reasons of wrong information were carelessness,change of operation plan,the disaccordance of charge made by computer with actual charge.Conclusion Through the analysis,the defects in hospital information management were identified and corresponding management countermeasures were proposed.更多还原