护理文书书写课程教学及实习带教现状的调查分析

The investigation and analysis on the current condition of theory class and clinical teaching in nursing document writing

目的:了解护校和实习医院对护理文书书写知识教学和培训的情况。方法:采用问卷调查法,调查2005年6月至2006年6月来我院的276名护士(新招聘护士104名,实习护士172名)在学校和实习期间接受护理文书书写知识培训的情况。结果:认为学校重视护理文书书写教学的人数只占29.71%;回答学校教完了护理文书全部课程、未授课、只讲了一部分内容的人数分别为15.90%、31.16%、52.90%;大多数学校和实习医院未对学生讲解护理文书相关法律法规;在带教老师的指导下实习护士参与记录的人数:手术护理记录4.81%,危重病人护理记录12.50%,医嘱单46.15%,体温单94.23%。结论:护校要规范护理文书书写的课程教学;带教老师要加强对护理文书书写的具体指导;岗前护理文书培训要注重讲解相关法律法规。

Objective： To find out the current condition of the teaching and training on the nursing document writing in teaching hospitals as well as in nursing schools. Method： One hundred and four newly-employed nurses and 172 nursing students were investigated by a questionnaire on the condition of nursing document writing training in nursing school. Results： Only 29,71% of them believed that the nursing schools attached importance to nursing document writing. Fifteen point nine percent of them said all nursing document writing lessons had been taught in nursing school 52.90% of them said part of nursing document lessons had been taught in nursing school, 31.16% of them said no nursing document writing lessons had been taught in nursing school. Most nursing schools and teaching hospitals didn＇t teach the rules of law related to nursing document writing. The proportion of the subjects who had recorded nursing documents under supervisor was 4.81%, 12.50%, 46.15%, and 94.23% respectively in operation nursing record, intensive nursing record, doctor＇s advice sheet, and temperatare sheet. Collusion： The writing of nursing document should be taught standardizedly in nursing schools, the clinical teachers should strengthen the tutoring of nursing document writing, the pre-post training of new nurses should pay more attention to the rules of law related to nursing document writing.