| Objective: The objective of this paper is to make an investigation on nurses’ medical record information utilization, cognition, demand and service recommendation, and further analyze the features of the demand of the nurses of different professional titles to provide a theoretical basis for nurses’ use of medical record information.Methodology: As a descriptive research, this study used the method of stratified sampling to make an investigation into a total of 362 nurses in 3 Class A tertiary comprehensive hospitals that have realized medical record digitization in Hebei Province. A “Questionnaire on Medical Record Information Resources Survey” was designed to survey research objects’ general information and the utilization, cognition and demand features of medical record information resources as well as the proposals for medical record information service. As there was no literature to refer to concerning nurses’ demand for medical record information resources, to know at what levels of nurses’ utilization of and demand for medical record information and with 296 clinicians as a reference, so this study was similar with the nursing group in the content of the questionnaire and the method of collecting the questionnaire. An analysis of medical record information resources was made from 4 aspects including nurses’ utilization, cognition, need and service recommendation. Also, this study made an in-depth analysis of the purpose, the period, and the contents of the nurses’ demand for medical record information. This study made resort to SPSS 13.0 statistical software for data processing, frequency and percentage for descriptive analysis and χ2 test. When P<0.05, the difference was seen to be statistically significant.Results:1 Nurses’ utilization of medical record information resources: 58.01% of the nurses had made use of the medical record information, 50.83% of them used it occasionally and only 7.18% used it regularly. The number of the nurses who often used medical record information was 31.42% lower than that of the doctors. The difference was statistically significant(P<0.01). 41.99% of the nurses had never used medical record information resources, 17.90% higher than that of the doctors, and the difference between them was also statistically significant(P<0.01).2 Nurses’ cognition of medical record information resourcesNurses’ grasp of medical record information retrieval service: 38.40% of the nursing staff that had a grasp of the service, 37.29% of them got an incomplete grasp and only 1.11% showed a complete grasp, clearly lower than that of the clinicians. Between the nurses and doctors, difference existed as to an incomplete grasp of the service(P <0.05), and a significant difference arose with regard to a good grasp and a poor grasp of the service(P<0.01).Channels of consulting medical record data: 74.59% of the nurses chose the medical record, 36.46% of them chose the archived electronic medical record and 25.97% the digital medical record. 62.84% of the doctors chose the archived electronic medical record. Difference of access channel was statistically significant(P<0.01).Channels of accessing medical record information service: Nurses derived medical record information service from colleagues, record rooms, pre-service training and tutors, accounting for 65.47%, 25.97%, 5.80% and 2.76% respectively, while doctors mainly from record rooms. Difference of access channels between them was statistically significant(P<0.01).3 Nurses’ demand for medical record information resourcesThe purpose of consulting medical record data: The nurses’ purpose of consulting medical record data was for thesis writing, knowledge accumulation, research project declaration, medical record quality control and clinical teaching, the proportion of which were 57.73%, 55.80%, 35.64%, 33.98% and 28.18% respectively. Compared with physicians, there was a significant difference in research project declaration, and thesis writing(P<0.01). Difference also existed in knowledge accumulation(P<0.05).Demand for the number of years of medical record information: 10.77% of the nurses chose the less-than-one-year post-discharge medical record data, 63.81% five-year post-discharge data, 19.90 % ten-year data and only 5.52% more-than-ten-year data with an obvious difference from that of physicians(P<0.01).Contents of the demand for medical record information: The contents of the nurses’ demand for medical record information consisted of nursing documents, operation notes, admission and discharge records, laboratory test reports and home page information, accounting for 76.80%, 62.43%, 58.29%, 57.73% and 48.62% respectively. There was a striking difference in the contents of the demand for medical record information(P<0.01) between the nurses and physicians for the physicians focused much on admission and discharge records and laboratory test reports.4 Recommendation for medical record information serviceHopes of knowing the method of medical record information service: 53.59% of the nurses chose the notice in the hospital network, 51.50% were in favor of collective training, 33.43% video play and 23.48% individual explanation. Compared with the doctors, difference arose in individual explanation(P<0.05)In terms of retrieval time: 14.36% of the nurses preferred 8:00-12:00, 11.88% 12:00-14:00, 56.63% 14:00-18:00, 34.25% 18:00-20:00, with no obvious difference from that of the physicians(P>0.05).Suggestions for improvement of medical record information service: 50% of the nurses thought service propaganda should be strengthened, 43.92% wanted to improve the reading environment, 43.37% expected a longer reading time, 18.78% hoped to further improve the medical record management skills, 17.68% thought that the medical record content needed to be perfected. Compared with the physicians, difference arising in service propaganda was statistically significant(P<0.01).5 The demand of the nurses of different technical titles for medical record informationThe purpose of the nurses of different professional titles to consult medical record data was to write a thesis, declare a research project and accumulate knowledge, the difference among which was statistically significant(P<0.01). There was a striking difference in the nurses’ demand for less-than-one-year and ten-year post-discharge medical record information(P<0.01). But, no obvious difference arose in the contents of consulting medical record data among the nurses of different professional titles(P>0.05).Conclusions:1 Nurses’ utilization and cognition level of medical record information is lower than clinicians’.2 Nurses’ main purpose to consult medical record data, especially nursing document, was to write a thesis.3 Nurses’ hopes were to strengthen medical record service propaganda, extend consulting time and improve service quality.4 Difference existed as to the motive and period of the demand for medical record information among the nurses of different technical titles. |
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