表格式专科护理记录单在优质护理示范病区中的应用效果

Application of nursing record form in high-quality nursing model ward in urology surgery department

目的设计泌尿外科表格式专科护理记录单并探讨其应用效果。方法根据泌尿外科专科特色设计表格式护理记录单,对98例住院患者同期使用新旧两种护理记录单进行书写记录,比较两种护理记录单所用的时间、纸张页数及质量评分差异。结果 98例住院患者表格式专科护理记录所用时间、纸张页数比原护理记录明显减少,质量评分明显提高。结论表格式专科护理记录单可大大减少护理记录时间及记录纸张页数,提高护理记录质量,且更能体现专科护理观察重点,利于了解患者的病情及诊疗护理进展,书写界面简洁明了,值得推广。

Objective To design nursing record form in urology surgery department and explore its application effects. Methods According to the characteristics of urology surgery department,we designed the nursing record form. The nursing record form and the original nursing record were used to record the nursing of 98 inpatients at the same time. The recording time, number of paper pages and quality control score were compared between the two kinds of nursing records. Results The recording time and number of paper pages with the nursing record form were less than those with the original paper record, and the qu^ity control score with the nursing record form was higher. Conclusion The nursing record form can reduce the recording time and number of paper pages,improve the quality of nursing records,better reflect specialist nursing focal points, and help the nurses to understand the patients＇ disease and treatment. Meanwhile the recording interface of the nursing record form is clear and concise.