Research on electronic nursing records versus manual nursing records

Objective To explore the different way of writing between electronic nursing records and manual nursing records and find out the difference between those two.Methods A clinical survey was conducted.2031 pieces of manual nursing records created between August 1 st and August 30th,2010 were used as group A,with an average hospitalization of 67.7 patients/day.2132 pieces of electronic nursing records created between August 1st and August 30th,2012 were used as group B,with an average hospitalization of 71 patients/day.Body temperature chart,medical order,and speed and quality of nursing record writing were investigated.The format of electronic nursing records was the same as that of manual nursing records.Results Group B spent much less time in body temperature chart drawing ([14.97 ± 0.46]batches/d [min],[0.21 ± 0.00] min/piece vs.[82.93 ± 1.92] batches/d [min],[1.23 ± 0.02] min/piece;t=70.23,120.82,P＜ 0.05),conduction of medical order ([80.67 ± 3.05] batches/d [min],[1.13 ± 0.04]min/piece vs.[187.93 ± 5.89] batches/d [min],[2.78 ± 0.05] min/piece; t=33.08,54.72,P＜ 0.05),and nursing record writing ([2.85 ± 0.21] min/piece,[1.72 ± 0.23] min/piece vs.[10.10 ± 0.47]min/piece,[4.99 ± 0.54] min/piece;t=28.24,11.13,P＜ 0.05) than group A.Conclusions Electronic medical records alter the process and methods of nursing care and improve work efficiency and quality,which is easier to retrieve,consult,and manage the nursing records. Key words: Electronic nursing record; Manual nursing record; Work efficiency