目的

总结以三维质量控制理论和戴明环（Plan-Do-Check-Act，PDCA）理论为模型构建介入信息化护理文书的应用效果及经验。

方法

以三维质量控制理论及PDCA 循环理论为理论框架，成立护理信息化小组，构建介入治疗患者信息化的全流程；应用临床护理信息化的评价量表回顾比较研究2021 年未采用护理信息化文书和2022 年、2023 年使用护理信息化护理文书书写的完整率、经济费用、护士使用的满意度及依从性等指标。

结果

构建了基于物法环的介入患者信息采集模式；构建形成了信息化的介入术前交接单、亚病种介入护理记录单、介入清点单、介入治疗安全核查单、介入患者信息登记单及介入术后交接单等15 类表单；形成了介入治疗的文书质控新模式；介入室护士对该系统模式的总体满意度维度得分为（4.44±0.61）分，使用依从性得分为（4.45±0.53）分；文书书写完整率由未使用前的94.63%提升到使用后的97.66%；单个病例平均纸张等相关费用由未使用前的2.80 元降低到1.56 元，使用前后的护理文书完整率及单个纸张的费用均值比较，差异有统计学意义（P ＜0.05）。

结论

基于两大理论构建的电子护理文书能够提高医护的依从性、满意度及电子护理文书书写的完整性，节省时间，减少纸张等费用消耗，能够促进介入室的护理信息化文书的发展。

Objective

To summarize the application effect and experience of interventional information a nursing document with 3D quality control theory and PDCA theory.

Methods

Taking 3D quality control theory and PDCA cycle theory as the theoretical framework， a nursing informatization team was established to construct the whole process of informatization for patients undergoing interventional therapy.The evaluation scale of clinical nursing informatization was applied to retrospectively compare the completeness rate of writing， economic cost， nurses' satisfaction and compliance in 2021 without using the nursing informatization documents and in 2022 and 2023 using the nursing informatization documents.

Results

The interventional patient information acquisition mode based on object method ring was constructed.Fifteen types of forms have been constructed， including preoperative handover sheet， sub-disease interventional care record sheet，interventional inventory list， interventional treatment safety verification form， interventional patient information registration form and interventional postoperative handover form； Formed.A new document quality control mode of interventional therapy wa formed.The overall satisfaction dimension score of the system model was 4.44±0.61 points， and the use compliance score was 4.45±0.53 points.The completeness rate of document writing increased from 94.63% before use to 97.66% after use.The average cost of related items such as paper per single case decreased from 2.8 yuan before use to 1.56 yuan.There were statistically significant differences in the completeness rate of nursing documents and the average cost of individual paper before and after use（P＜0.05）.

Conclusion

The electronic nursing documents constructed based on the two major theories can improve the compliance， and satisfaction of medical staff and the completeness electronic document writing，save time and reduce expenses， and can be promoted in peers.