陈洁+邓淑红+徐芳

[摘要]目的 研究医护一体标准化管理模式在电子医嘱流程中的应用价值。方法 选择我科2015年7月～2016年6月的200例住院患者，随机分为观察组和对照组，各100例。对照组应用传统电子医嘱流程，观察组应用医护一体标准化电子医嘱流程，观察两组的医嘱处理速度、医嘱错误率、收费错误率。结果 观察组的医嘱错误率为3%，医嘱处理速度为（20.8±13.6）min/100条；对照组的医嘱错误率为8%，医嘱处理速度为（23.7±12.8）min/100条，两组比较差异有统计学意义（P<0.01）。观察组的收费错误率为17%，低于对照组的21%，差异有统计学意义（P<0.05）。结论 将医护一体标准化管理模式应用于电子医嘱流程中，可使医嘱书写、录入规范化，医嘱处理程序化，能够提高医嘱处理的准确度、速度，加强医护协作，完善收费机制。

[关键词]医护一体；电子医嘱医院信息系统；标准化管理

[中图分类号] R197.324 [文献标识码] A [文章编号] 1674-4721（2017）02（b）-0166-03

[Abstract]Objective To study the application value of standardization management model of doctor-nurse integration in electronic medical order process.Methods 200 patients from July 2015 to June 2016 in our department were selected，according to a random number table method，200 cases were divided into the observation group and the control group，100 cases in each group.The control group was given the traditional process of electronic medical order，the observation group was given the standardization management model of doctor-nurse integration in the process of electronical medical order.The speed of managing medical order，the error rate of medical order and the error rate of charge of the two groups were compared.Results The error rate of medical order in the observation group was 3%，the speed of managing medical order in the observation group was （20.8±13.6） min/100 items.The error rate of medical order in the control group was 8%，the speed of managing medical order in the control group was （23.7±12.8） min/100 items，there was significant difference between the two groups （P<0.01）.The error rate of the observation group was 17%，which was lower than that of the control group （21%），with significant difference （P<0.05）.Conclusion The standardization management model of doctor-nurse integration in the process of electronical medical order can regulate the medical order writing and entering，program the manage process of medical order，improve the accuracy and speed of medical order management，strengthen medical collaboration and perfect the charging mechanism.

[Key words]Doctor-nurse integration；Electronic medical order hospital information system；Standardization management

醫院信息系统（hospital information system，HIS）是现代化医院建设中不可缺少的基础设施与支撑环境，电子医嘱是医院信息化建设到一定程度的必然产物，是实现医务流、财务流、物流信息互通共享的有效途径[1]。HIS的运作以医生开立电子医嘱为源头，一切围绕电子医嘱展开，电子医嘱成为患者诊疗过程中的核心，不仅直接影响护士站的工作，还主导周边检验信息系统（LIS）、医学影像信息系统（PACS）等。一方面HIS系统是以财务、物流为中心设计，缺少对医疗项目的制订，电子医嘱实际上和收费清单并无区别[1]。另一方面HIS系统要求医生输入电子医嘱非常精确，需分清医嘱类型，准确地输入药品用法、剂量、给药途径，准确输入检验项目、标本类型、执行科室等。在实际工作中，由于医护人员任务繁重、对物价政策理解不透彻、掌握不彻底[2]、医嘱录入不规范[2-4]、医生对电子医嘱操作程序……