综合性ICU患者监护记录单临床应用的前瞻性研究

Perspective study on clinical application of monitoring record list for comprehensive ICU patient

目的研究新时期综合ICU患者的临床监护记录单，以保证患者及护士使用过程的便利及安全。方法将我院ICU自2002年使用的“图标式ICU监护记录单”，在原表格的基础上根据综合ICU患者需要多系统监测的特点进行修订，主要以数字和符号表示形式形成新的护理记录表格，并采取对比的方法考证新旧两种表格的效用。结果两种表格各项指标比较：相同人数的护士分别填写两种不同表格所使用的时间分别是新表格平均（66±11）min，旧表格平均（97±10）min，每份表格的分数设为100分，护理质量检查小组检查的结果，新表格平均（97±2）分，旧表格平均（94±2）分，两组时间及分数比较差异有统计学意义（t=10．6263，4．0307；P〈0．01）；新旧表格使用合格率比较差异有统计学意义（90．12％比82．62％，x2=67．49，P〈0．01）。结论新的监护记录单更科学、更全面、简洁、更适合综合ICU不同种类的患者的记录要求，减轻护士工作量，减少记录时间，提高工作效率。

Objective To study clinical monitoring record list for comprehensive ICU patient in new age and to ensure convenience and safety when used by nurses and patients. Methods We have revised the ＂Icon ICU Monitoring Record List＂ used for ICU in our hospital since 2002, basing on the original form and according to the characteristics of comprehensive ICU patient that need multi-system monitoring, mainly in numbers and symbols to produce new kind of nursing record form, and used contrastive method to research into the utility of new and old forms. Results After comparison of all indexes of two forms, the result is as follows ： the time used by same numbers of nurse to fill in two kinds of form is （66 ± 11 ） minutes for the new form and （97 ± 10） minutes for the old. The score set for each form is 100. The examination by the nursing quality inspection team shows that the new form got an average score of （97 ± 2） and the old form got （94 ± 2 ）. The comparison and difference of the two groups in time and score is statistically significant （ t = 10. 626 3,4. 030 7 ; P 〈0. 01 ）. Pass rate of new form was 90. 12% , and 82.62% for old one, and difference was significant （X2 = 67.49, P 〈 0. 01 ）. Conclusions The new monitoring record list is more scientific, more comprehensive and simple and is more suitable for recording all kinds of patient in comprehensive ICU. It will lighten the work on the nurse, reduce time of record and improve work efficiency.