摘要
目的优化ICU护理记录单,减少护士护理记录书写量,连续、动态、客观反映患者病情变化,提高临床护理工作质量。方法根据科室特点设计表格、文字书写相结合的记录单,并与原ICU护理记录单比较。结果新旧两种护理记录单在记录信息量、书写耗费时间上的差异均有统计学意义(P<0.05)。结论优化后的ICU护理记录单书写时间明显减少,记录信息量更大,书写质量显著提高,护士业务水平不断提升。
Objective To optimize ICU nursing records sheet and explore an optimal way for nursing records which is time saving,convenient and suitable for continuous ICU monitoring. Methods A new ICU nursing records sheet was designed in- tergrated with tables and notes. The information and writing time were compared between the new nursing records sheet and the former one. Results Compared with the former nursing records sheet,the writing time was reduce and the information was increased in the new nursing records sheet（P〈0.05）. Conclusion The new nursing records sheet can reduce the writing time with more information ,which can improve the quality of nursing.
出处
《中华护理杂志》
CSCD
北大核心
2011年第10期983-984,共2页
Chinese Journal of Nursing
关键词
重症监护病房
护理记录
表格和记录管理
Intensive Care Units
Nursing Records
Forms and Records Control
