泌尿外科交接班记录单的设计与应用

Design and application of hand-over records in urology

目的将交接班内容以表格形式记录，简洁、全面的反映护理工作内容，提高工作效率，防范护理差错。方法设计并实施“泌尿外科交接班记录单”，总结记录单实施前后的漏执行医嘱和未及时执行医嘱的发生例数，评价效果。结果使用新设计记录单后，护理缺陷总发生率降由0．711％至0．042％，与使用前比较，差异具有统计学意义（x2=80．743，P〈0．01）。结论交接记录单的应用，使护理工作内容简洁、有序，直接延长护理时间，实现了护理零差错。

Objective To express the contents of records in table format, reflect the content of care in concise and comprehensive manner, improve efficiency and prevent nursing errors. Methods Designed and implemented, ＂Urology shift relief records＂, concluded the leakage recorded before and after the implementation of a single prescription and non-occurrence of doctor＇ s advice and timely implementation of the number of cases. The effect was evaluated. Results Nursing defection rate has reduced to 0.042% in new designed records, and was different from those before designing （0.711% vs 0.042%, ~2 = 80.743, P 〈 0. 01 ）. Conclusions The application of the transfer of a single record made care concise, orderly, and directly extent nursing time, and achieve zero errors in nursing.