中医表格式护理记录单的设计和使用

The design and application of nursing record form in Traditional Chinese Medicine

目的探讨一般患者中医表格护理记录单的设计方法和使用效果。方法自行设计中医表格式护理记录单,将1186例患者分为两组,每组593例,实验组采用中医表格式护理记录单,对照组采用文字式护理记录单,观察两组完成记录所用的时间及中医护理要点记录完整性的差异。结果实验组完成记录所用时间少于对照组,中医护理要点记录的完整性高于对照组(P<0.01)。结论中医表格式护理记录能缩短记录书写时间,提高工作效率,能较全面地反映中医护理观察要点,体现中医护理特色。

Objective To explore the designed method and evaluate the application of nursing records form in Traditional Chinese Medicine. Method A nursing records form in Traditional Chinese Medicine was designed and applied in 593 patients. While the nursing records for the other 593 patients in control group were recorded with literal description means. Then, the time and quality of nursing records were compared between the two groups. Result Compared with the control group, the time was shorter and the quality of nursing records was significantly better in the experimental group （ P 〈 0.01 ）. Conclusion The application of nursing records form in Traditional Chinese Medicine can shorten the time of nursing recording,improve work efficiency, fully reflect the key points of nursing observations and embody the features of Traditional Chinese Medicine.