特别护理记录单的改进与应用

Improvement and Application of Special Nursing Care Record Chart

目的 探索一种省时、便捷,适合我国加入WTO后与国际接轨的危重病人护理记录表格与记录方法。方法将原来的特别护理记录单和叙述性文字记录方式整合为1张中英文对照式表格(特护记录单),包含病人一般情况、监护内容、治疗护理措施、出入量及病情简记及签名五部分内容。在记录中使用数字、打勾、英文缩写字母或符号等,必要时用简洁的文字补充说明。结果经临床应用11个月、982例病人,使用者认为记录便捷省时,能及时、动态、全面、真实地反映病人的病情变化及治疗护理情况,利于质控。结论 特别记录单设计科学、简洁,易于操作,长期使用有助于提高护理质量,同时对学习英语有促进作用。

Objective To search a kind of dying patient's nursing care record chart and a way of record that is time-saving, convenient and suitable for international connection after China joined WTO. Methods Previously special nursing care chart was combined with descriptive note to form a chart that included Chinese and English versions. The contents in this chart included 5 parts; patient's general conditions, monitoring, treatment and nursing intervention, intake and output, concise record of patient's conditions and signature. Number, tick, abbreviated English alphabet or symbols etc. were used during recording, brief record was used for additional supplement if necessary. Results The record has gained a very good effect after clinical application in 982 patients for 11 months. Conclusion This special nursing care record chart is beneficial to improve the quality of nursing care and promote English study at the same time.