外科表格式护理记录单的设计使用及效果

Design,application and effect of surgical tabular nursing record sheet

目的:设计使用外科表格式护理记录单,减少文字书写量,客观真实准确反映护理活动过程,提高临床护理工作质量。方法:根据科室特点设计护理记录表格,采取填番号与文字书写相结合,将入院评估融入护理记录单,并与原护理记录单比较。结果:新旧两种记录单在书写耗时的差异有统计学意义(P<0.05)。结论:采用设计后的表格式护理记录单记录信息更精准,书写耗时明显减少,书写质量显著提高,护理工作质量不断提升。

Objective：To design and apply surgical tabular nursing record sheet in order to reduce the nursing record written quantity, reflect nursing process objectively, truly, and accurately , and improve the quality of clinical nursing work. Methods：The nursing record sheet was designed on the basis of the characteristics of surgery, combining with filling in numbers, writing, and in- tegrating the admission assessment sheet to the nursing record sheet. Further, the new and the original nursing record sheets were com- pared. Results： The difference between the new nursing record sheet and the old one were statistically significant in the time for writing （P〈0.05）. Conclusions： After the designed tabular nursing record is applied, the records can be more informative, the writing time has been significantly reduced, and the writing quality has been improved. All in all, the clinical nursing work is continuously im-proved.