表格式一般患者护理记录单的设计与临床应用

Design and clinical practice of the tabular nursing record form

目的改进一般患者护理记录书写方法，以减轻护士书写负担，体现专科护理的特点。方法以护理程序为框架，以病人为中心的原则设计护理表格，包括病人入院首次护理记录、住院过程中的护理记录、出院护理记录、出院指导，均设计为表格式，将不同专科疾病将常见的并带有共性的观察重点、护理措施等横向列入表头项目栏，同一专科不同疾病或同一疾病不同个体特异性观察要点、病情变化、护理措施、护理效果等留空格由护士书写，比较实施表格式前后护理病历质量，对一般患者护理记录从客观性、准确性、及时性、完整性、规范性、专科性等方面进行对比分析。结果应用表格式护理记录后护理记录总分及各项评分结果与传统式护理记录方法均有提高，差异有统计学意义（P〈0．05）。护士普遍反映明显缩短了书写时间。结论表格式记录具有实用性，书写简单、省时，书写质量提高。护理记录单表格化有利于临床护理工作，值得推广。

Objective To modify the nursing record form in order to ease workload of nursing and to show the characteristic of professional nursing. Methods Under guidance of patient-centered nursing process, the tabular forms including the first nursing record of inpaticnts, nursing record of patients during hospitalized period, nursing record of discharged patients, guidance of discharged patients were designed. General observation keynotes and nursing measures were listed as row and special keynotes wrote by nurses were designed as column. The quality of nursing records including its objectivity, accuracy, timeliness, integrality, standard degree and specialization were compared between before and after used modified nursing records. Results In quality of nursing records, tabular forms was better than the old forms. The time of nursing record significantly shortened. Conclusions Tabular nursing record forms have practical, simple, time-saving feature. It is useful in nursing practice.