医护联合查房的临床实践及体会

Joint Ward-round of Doctors and Nurses in Clinical Practice

目的探讨管床医生与责任护士联合查房对医护记录、护理级别、患者满意度的影响。方法选择本院泌尿外科作试点科室,2014年3—5月387例住院患者采用传统查房模式进行查房(传统查房组),2014年6—8月412例住院患者采用管床医生与责任护士联合查房的模式进行查房(联合查房组),通过质控运行病历并记录医护记录不一致情况;评估患者病情和生活自理能力并与护理级别对照;进行满意度调查。结果联合查房组较传统查房组医护记录不一致明显减少(P<0.05),护理级别准确率明显提高(P<0.01),患者满意度提高(P<0.05)。结论管床医生与责任护士联合查房可有效减少医护记录不一致现象,护理级别更准确,提高患者满意度。

Objective To explore the effect of joint ward-round of doctors with nurses on medical records and patients＇ satisfaction. Methods Conventional ward-round was conducted among 387 patients in Urology Department from March to May 2014 and joint ward-round of doctors with nurses was performed among 412 patients from June to August 2104. Medical records between doctors＇ and nurses＇ and patients＇ satisfaction were compared after different types of ward-round. Results Significant decrease was observed in the disagreements between doctors＇ and nurses＇ records （P〈0.05）; the correct rate of nursing level identification （P〈0.01） and patients＇ satisfaction were improved （P〈0.05）. Conclusion 3oint ward-round of doctors and nurses benefits the decrease of disagreement between doctors＇ and nurses＇ record, the appropriate identification of nursing level and the improvement of patients＇ satisfaction.