简化儿科护理文书书写的方法探讨与效果评价

Discuss and evaluate the effect of simplifed method of pediatric nursing documents writing

目的通过简化病区护理文书的书写,探索护士回归护理本源,力争时间、空间,为患者提供直接的护理服务,减轻护士书写负担和拖班,提高护理服务满意度。方法收集30名护士在实施简化护理文书书写前后的情况,对护理文书书写的时间、因护理文书书写造成拖班、因护理文书书写产生书写负担和临床护理服务满意度进行调查,探讨简化护理文书书写的方法。结果实施简化的护理文书书写后,86.7%的护士每天书写护理文书时间不超过1 h(P<0.05),96.7%的护士没有拖班的现象(P<0.01),96.7%的护士认为减轻了书写的负担(P<0.01),临床护理服务质量满意度达97.5%(P<0.05)。结论采用简化护理文书书写,护士有更多的时间和精力为患者提供直接的护理服务,促进护士贴近临床,提高科室临床护理服务质量。

Objective By Simplifing the method of pediatric nurses documents writing,nurses have much time and energy to do their work for patients,on the other hand to reduce their workload and overtime.Methods Compare 30 nurses use new method and old mehtods of ducunment writing with the time of document writing,rate of ovework,presure of writing and Service satisfaction to discuss the new methods practicality.Results 86.7% nurses＇ writing time less than one hour（P0.05）,96.7% nursus had no ovetime（P0.01）,96.7% nurses fell the new methods reduce d their workload,97.5% patients were satisfied the service（P0.05）.Conclusion Nurses have much time and energy to do clinic work for patients by using the simplifed methods of documents writing and the new methods can improve the nursing service quility.