手术室护理记录信息化对护理单书写质量及护理质量的影响

Influence of Informationization of Nursing Records in Operating Room on the Quality of Nursing Records List Writing and Nursing Quality

目的探讨手术室护理记录信息化对护理单书写质量及护理质量的影响,以提高护理文书质量。方法选取某院2019年1月1日-2019年12月31日手术室工作的22名护士的90份护理记录单为研究对象,以2019年6月1日为应用信息化管理的时间节点,将6月1日之前的22名护士的45份护理记录单作为对照组,将6月1日之后的22名护士的45份护理记录单作为观察组,比较2组记录单书写质量、书写缺陷发生情况及患者对各项临床护理质量的评分。结果观察组护理记录单书写时效性(100.00%)、完整性(100.00%)及正确性(95.56%)均显著高于对照组(75.56%、80.00%、71.11%)。观察组护理记录单各项书写缺陷的发生率均显著低于对照组。观察的管道护理(95.64±1.72)、健康教育(95.86±1.76)及皮肤护理(98.53±1.86)的评分均显著高于对照组[(90.11±1.65)、(91.74±1.72)、(92.48±1.81)]。结论信息化手术室护理记录能够提高护士书写护理记录单的质量,减少书写缺陷,更及时、完整、准确的手术室护理记录能够有助于提高临床护理质量。

Objective To explore the influence of informationization of nursing records in operating room on the quality of nursing notes writing and nursing quality.Methods To choose the 90 of nursing records list of 22 nurses worki ng i n operati ng room of a hospital from January 1 st,2019 to December 31 st,2019 as the research object,and choose J une 1 st,2019 as time nodes for the informatized management.45 of the nursing records list of 22 nurses before June 1 st were chosen as control group,and 45 of that after June 1 st were chosen as observation group,then compared two groups record writing writing quality defect occurrence score of the quality of clinical nursing and patients.Results The timeliness(100.00%),completeness(100.00%)and correctness(95.56%)of the nursing records in the observation group were significantly higher than those in the control group(75.56%,80.00%and71.11%).The incidence of writing defects in the nursing records of the observation group was significantly lower than that of the control group.Observation tubes(95.64+/-1.72),and health education(95.86-1.76)and ski n care(98.53+1.86)score were significantly higher than the control group[(90.11+1.65),(91.74-1.72),(92.48-1.81)].Conclusions Informationized operating room nursing records could improve the quality of nurses writi ng nursi ng records,reduce writi ng defects,more ti mely,complete and accurate operati ng room nursi ng records could improve the quality of clinical nursing.