骨折患者护理行为记录方法的改进与效果评价

Improve the Record Methods to Nursing Action in rescuing the fracturing patients

目的比较两种格式的护理记录单,探讨护理行为记录的意义和记录效果评价。方法对20例股骨骨折急诊住院行骨牵引和切开复位、交锁钉内固定术的患者的60张护理记录单进行分组比较,分析新旧两种记录单的使用方法和应用效果,探讨护理记录单的使用意义和价值。结果根据《医疗事故处理条例》规定的护理记录内容范围和法律要求,结合临床实际设计护理记录单能真实反映患者接受的护理技术服务,有利于提供举证的法律依据;护理行为指南随时指导护士评估患者的护理问题选择规范的服务项目;用代码标记护理行为能节省记录的时间;补充医嘱单以外的护理技术服务收费项目,体现护士劳动价值等,因而受到护理人员的肯定。结论研究护理行为记录方法对于更好地贯彻《病历书写基本规范(试行)》的原则,提高护理记录书写质量,改进护理服务有较好的临床意义和应用价值。

Object This article probes into the documentatim of the nursing a ctions and its evaluation. Methods Twenty emergent patients with femoral fractur e were performed by traction and interlocking femoral intramedullary nail fixati on. These patients were assigned into 2 groups and the nurses made the detailde records with different record form. The authors analyze and compare the applied effect,and then inquire the value and meaning of the recording methods in practi ce. Result According to the relative provision to the content of the nursing rec ord in the Statute to the Disposal of Medical Accidents,the record designed with the clinic experience accurately reflect the nursing technology service that th e patient receive in the hospital,which can be used as the witness if there is a case happened in the court.coding the nuring actions can save the time for doca mentation efficiently. The guideline to the nursing action can uses as the guid ance to the nurse in choose the regular service items in terms of the patients'p roblem in nursing. It also provide evidences the nursing service expensive besid e the order, and materialize the nurses' labor value and by which the value of t he nurses'service should be admitted. Conclusion It is useful and meaningful to probe into the principle of the basic principle of recording the patients'record ,which can improve the quality of the nursing record,mend the nursing service.