脑血管病急性期护理病案记录单的设计及内容管理

The design and management of nursing case records for patients with acute cerebrovascular disease

目的探讨脑血管病急性期患者护理病案记录单设计及内容管理。方法对护理记录单进行设计，采用填空式的记录方式，减少文字重复书写及记录时间，将患者生命体征的变化，反映神经科专科特点的神志、瞳孔、瘫痪肌力的变化记录体现时间性；并对其记录的内容包括新患者入院时的记录、住院期间记录、出院记录等进行管理。结果新患者入院时的记录，住院期间的记录，出院记录均根据专科的特点记录。结论脑血管病急性期住院期间护理病案记录单设计与内容管理，对提高护理质量有深远的意义。

Objective To discuss the design and content management of the nursing case records for patients with acute cerebrovascular disease. Methods We modified the former nursing ease records （NCR） by adopting the ＂filling in the blank＂ recording style and reducing time cost for repeated writing. The new NCR demonstrated the time characteristic of vital signs changes and neurological signs changes such as consciousness, pupil and paralyzed muscle strength. It could also superintend the record of admission, hospitalization and discharging of patients. Results It met a standardized nursing record management after the modification and showed the specialized nursing services with simplified and integral charac- teristics. The new NCI fitted legal requirement, protected the rights of nurses and favored for the quality control and management of nursing cases. Conclusion The newly modified NCI contributes to the nursing quality for hospitalized patients with acute cerebrovascular disease.