表格式护理记录单在神经外科的应用效果

The effect of form＇ nursing records in neurosurgery application

目的减少护士书写时间，使护理记录科学化、规范化和简洁化，提高护理措施落实率。方法设计一套符合实际的神经外科表格式护理记录单，并与综述式护理记录单应用情况进行比较。结果每位护士平均书写每份护理记录的时间由10．85min降至2．99min；经统计学处理（P〈0．001），差异有统计学意义。另外，表格式护理记录组书写表格的整洁度、记录及时性及护理措施的正确和到位率与综述式护理记录组比较（P〈0．01）差异有统计学意义。结论神经外科表格式护理记录单的设计符合表格设计的要求，操作简便，极大地减少了护士书写时间，更注重护理措施的落实，使病人得到更全面、准确的护理。

Objective To make the nursing records scientific, standard and succinct, save the descriping time and raise the performance rate of nursing process. Methods To redesign a new bind of form which was fit for lotto＇nursing records of neurosurgery. And compare it with the summary of single - care record groups. Results The mean time used in writing nursing records was decreased from 10. 85 minutes per nurse per nursing record to 2. 99 minutes. Moreover, The form of nursing record groups was improved in the form the entire fineness, record timeliness and the nursing measure correct and the arriving rate than the summary of single - care record groups. （ P 〈 0. 001 ） . Conclusions The form＇ nursing records in neurosurgery form conforms to the request of form designing. And it＇s simple to use. So it saves the time in writing nursing records. Also, it puts the nursing intervention into effect. Then the patients can get holistie care..