摘要
目的对综合ICU患者的临床监护记录单与传统使用的图表式ICU监护记录单进行比较分析。方法本院ICU将2002年使用的"图表式ICU监护记录单"根据综合ICU患者需要多系统监测的特点进行修订,形成以数字和符号形式为主的新护理记录表格,并比较新旧2种表格的差异性。结果相同人数的护士分别填写同一患者病情资料采用2种不同表格所使用的时间分别是新(85±11)min,旧(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,2组时间及分数比较差异有统计学意义(P<0.05)。结论新的监护记录单更科学、更全面、更简洁、更适合综合ICU不同种类的患者的记录要求。新监护记录单的使用有利于减轻护士工作量,减少记录时间,提高工作效率。
Objective To compare and analyze the difference between the comprehensive ICU monitoring recording sheet and the tabular ICU monitoring recording sheet.Methods Modified the tabular ICU monitoring recording sheet to meet the requirement that ICU patients need multisystem monitoring.Numbers and symbols were the main form of the new monitoring recording sheet.Then compared and analyzed the difference between them.Results The time of using the comprehensive ICU monitoring recording sheet and the tabular ICU monitoring recording sheet to record the same patient condition data by the same number of nurses are（85±11）min and（97±10）min.Each recording sheet is totally divided into 100 points,the quality of care inspection team give（97±2）to comprehensive ICU monitoring recording sheet and（94±2）to tabular ICU monitoring recording sheet.There were significant difference between these two monitoring record sheet in time for recording and quality evaluation scores.Conclusion The comprehensive ICU monitoring recording sheet is more scientific,more comprehensive,more concise,and more suitable for different types of critical patients＇ requirements.Using the comprehensive ICU monitoring recording sheet could reduce the workload of nurses,decrease the recording time,and improve the efficiency.
基金
广西卫生厅2010科研立项项目(研究项目合同号:Z2010460)
关键词
危重患者
ICU监护记录单
护理记录
Critical Patient
ICU Monitoring Recording Sheet
nursing record
