围手术期护理记录单的设计及应用

Design and application of a modified perioperative nursing record

目的探讨围手术期护理记录单的设计及应用效果。方法自行设计围手术期护理记录单并应用于外科,比较改进前后书写时间及护理人员对表单的效果评价。结果改进后36名护士书写同病种围手术期护理记录单时间少于改进前,护理文件质量评分高于改进前,护士对围手术期护理记录单的节约书写时间、内容全面、重点突出、记录客观准确、具有书写提示性方面的满意度评分均高于改进前,差异有统计学意义(P<0.05)。结论围手术期护理记录单的应用有利于简化护理文件书写,规范护理执业行为,提高工作效率和节约护士书写时间。

Objective To explore the design and application effects of a modified perioperative nursing records.Methods A modified perioperative nursing record was self-designed and applied to surgical wards.The record time and effect evaluation by nurses were compared before and after modification.Results After modification,the perioperative nursing records on the same diseases of 36 nurses had less record time and higher record quality when compared to before modification（P〈0.05）.The results of the evaluation questionnaires from five out of six nurses demonstrated that the design was better than before modification（P〈0.05）.Conclusion The application of the modified perioperative nursing records can standardize the nursing practice,enhance the efficiency of work and improve the quality of nursing records.