表格式护理记录书写指南在耳鼻咽喉科的应用探讨

Discussion on the application of the writing guideline of tabular nursing records in otolaryngology department

目的探讨表格式护理记录书写指南在五官科的应用效果。方法对照组资料选定2007年lO月-2009年2月在我科住院的120例病人的护理记录，实验组资料选定2009年3月-2010年5月在我科住院的120例病人的护理记录，两组病人的护理记录均采用我科自行设计表格式护理记录，对照组护理记录由责任护士常规记录，实验组护理记录组织学习并应用表格式护理记录书写指南由责任护士进行记录。结果应用表格式护理记录书写指南前后，两组护理记录书写质量比较，经统计学分析，P值均〈0．05，差异具有统计学意义。结论应用表格式护理记录书写指南来指导临床护士书写护理记录是可以保证书写的完整性、及时性、动态性和规范性，从而提高了表格式护理记录的书写质量。

Objective To study the effect of the writing guideline of tabular nursing records in otolaryngology department. Methods There were two groups, each group of 120 nursing records. Experimental group was finished between October 2007 to February 2009, and control group was finished between March 2009 to May 2010. Nursing records of each group were recorded by self-deslgned table. Control group was taken regularly by the nurses on duty, experiment group was taken by the nurses who had been trained applying the writing guide- line of the nursing records. Results The qualities of nursing records writing were compared between before and after applying the writing guideline of tabular nursing records as well as two groups, there were statistical differences （P 〈 0. 05）. Conclusions The writing guide- line of nursing records can guarantee the integrity, effectiveness, dynamic characteristics and specification of nursing notes taking, as well as promote the quality of itself.