术前访视与手术室临床教学

Application of preoperative interview recording list in clinical teaching in operating room

目的:探讨术前访视记录表在手术室临床教学中的应用效果。方法:设计术前访视记录表,应用于2001级护生,结合术中护理,进行护理查房、术前讨论、每日反思、护理文书规范等,并对教学结果进行评价;比较护理文书规范前后护生护理记录情况,分别对护生和病人进行问卷调查。结果:病人对手术室护理工作满意度达98.5%,无护患纠纷发生;2001级护生平均成绩较2000级护生成绩提高11.27分;术前访视记录表的应用对规范护生护理文书记录有显著性意义。结论:术前访视记录表符合手术室整体护理工作特点及护理要求,适用于手术室临床带教及推广使用。

Objective：To discuss the chinical value of the pre-operative interview recording list in the field of clinic teaching in operating room（OR）.Methods：The Preoperative interview recording list was utilized on the nurse students（the 2001 grade）.Combined with the intraoperafive nursing, nursing ward inspection, preoperative discussion, daily reflecting and reyulation of the nursing documents, the evaluation was performed on the teaching results, and the questionnaire survey was made on the patients and nurse students respectively.Resuits：Each person completed 20 cases, the total was 720.98.5% of the patients were satisfied with the services by the nurse students, and no trouble occurred between the nurses and patients;the average achievement in the nurse students （the 2001 grade）increased by 11.27 points compared with that in the nurse students（the 2000 grade）,the application of the preoperative interview recording list had significant value on nursing recording regulation.Conclusion：The preoperative interview recording list is in keeping with the charaterlstie and requirement of holistie nursing in OR, therefore it can be used in ehinical teaching and some other fields.