电子健康记录系统应用背景下护士文书负担的范围综述

doi:10.3761/j.issn.1672-9234.2026.06.018

摘要/Abstract

摘要：

目的对电子健康记录（electronic health record，EHR）系统应用背景下护士文书负担的研究进行范围综述，为后续研究与实践提供依据。方法遵循范围综述方法学框架，检索中国知网、万方数据库、中国生物医学文献数据库、PubMed、Web of Science、EBSCO、OVID、Cochrane Library，检索时限为建库至2025年6月20日，由2名研究者独立完成文献筛选与资料提取。结果共纳入30篇文献。EHR系统应用背景下护士文书工作包括结构化护理记录、医嘱执行与治疗支持文书、护理交接与协作沟通文书、质量管理与监管导向文书，以及EHR系统操作与信息维护相关工作5类。评估工具包括主观评估工具（如美国国家航天航空局任务负荷指数量表、护士与助产士文书负担评估工具）和客观评估工具（如时间-动作研究、工作日志分析、时间戳数据分析）。影响因素包括技术、任务、组织、政策、个体多个层面。干预方法聚焦于技术优化、流程再造、组织变革等。结论 EHR系统应用背景下护士文书负担普遍且显著，未来应进一步加强该主题的系统研究，为护士构建高效、人文的工作环境，促进护理职业可持续发展。

关键词: 护士, 电子健康记录, 文书负担, 范围综述

Abstract:

Objective To conduct a scoping review of studies on nursing documentation burden in the context of electronic health record（EHR） system application. Methods Following the methodological framework of scoping reviews，computerized searches were performed in CNKI，Wanfang Database，SinoMed，PubMed，Web of Science，EBSCO，OVID，and Cochrane Library. The search period spanned from database inception to June 20，2025. Two researchers independently conducted literature screening，inclusion，and analysis. Results A total of 30 studies were included. The findings indicated that nursing documentation in the context of EHR system application could be classified into five categories：structured nursing records，documentation supporting physician order execution，documentation related to hand-offs and inter-professional communication，documentation for quality management and regulatory requirements，and EHR system operation and information maintenance tasks. Assessment tools comprised two categories：subjective assessment tools（e.g.，National Aeronautics and Space Administration Task Load Index，Burden of Documentation for Nurses and Midwives） and objective assessment tools（e.g.，time-motion studies，work log analysis，timestamp data analysis）. Influencing factors encompassed multiple dimensions：technological，task-related，organizational，policy-related，and individual. Intervention methods focused on technological optimization，workflow redesign，and organizational change. Conclusion The burden of nursing documentation in the context of EHR system application is prevalent and significant. Future efforts should further strengthen systematic research on nursing documentation burden，in order to build an efficient and humanistic working environment for nurses，and promote the sustainable development of the nursing profession.

Key words: Nurses, Electronic Health Records, Documentation Burden, Scoping Review

田凤, 陈媛, 陈诗琪, 张榕祥, 朱晨阳. 电子健康记录系统应用背景下护士文书负担的范围综述[J]. 中华护理教育, 2026, 23(6): 760-768.

TIAN Feng, CHEN Yuan, CHEN Shiqi, ZHANG Rongxiang, ZHU Chenyang. Nurses’ documentation burden in the context of electronic health record system application：a scoping review[J]. Chinese Journal of Nursing Education, 2026, 23(6): 760-768.

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