表格式护理记录单的使用与效果

Practice and effects of tabular nursing records

目的探讨表格式护理记录单在临床使用的效果。方法成立表格式护理记录专业指导小组,设计表格式护理记录单,先在试点科室进行试用,对全院护士进行培训后全面推广使用。结果护理记录时间缩短,护理记录质量提高,护士对护理记录满意度提高(P<0.01)。结论推行表格式护理记录单使用的过程中必须注重护士的学习标准,注重对护士进行培训指导,提高其认识,才能确保护理文书简化工作的顺利进行,从而确保护理记录质量持续改进。

Objective To explore the effects of using tabular nursing records. Methods The reform measures included establishing the guidance group, designing tabular nursing records, and training nurses. The charts were used in pilot wards and then applied in all wards after training nurses. Results After the application of tabular nursing records, the time for documenting nursing records was shortened, and the quality of documenting nursing records was improved, and nurses＇ satisfactory with the nursing record was increased （ P 〈 0.01 ）. Conclusion In the process of applying the tabular nursing records, we should pay attention to the relevant standards, training and guidance of nurses, increasing the awareness to ensure the application of simplified nursing charts and the continuous improvement of documenting nursing records quality.