新生儿入院评估表的设计与应用

Design and application of neonate hospitalization estimate form

笔者针对该院统一使用的护理入院评估单对新生儿科不适用的问题,根据新生儿科及NICU病房护理对象的特点和要求,本着收集资料内容与护理有关,尽量避免与其他专业人员收集的资料重复的原则,对新生儿护理入院评估单进行了表格化设计。其特点是条理清晰、专科特点突出和使用简便。既发挥了评估单对护理评估的指导作用,又保持医护文书统一性,便于文件保存及内部审核。

According to the trait and the requirement of nursing object in dept. of neonatology and NICU, the authors designed a special form about neonate estimate of hospitalization aiming at the problem that unified estimate form used in all wards was not adapted in neonate ward. The design of form followed the principle that nursing should be related closely and repetition with other specialty should be avoided in collecting data. The estimate form bears the trait of consecution in focus, prominent special characteristic and briefness and convenience in use. The estimate form which not only plays a guided role to nursery estimate, but also maintains unification of medical and nursing document, is beneficial to preservation and interior auditing of document.