日间手术临床护理记录单的设计及应用体会

Design and application of clinical nursing record in day surgery

日间手术具有住院时间短、病种多、周转快、护理工作量密集的特点,其工作流程不同于普通病房的模式。根据其流程特点,我科设计了表格式临床护理记录单,规范了交接过程的关键环节,减少书写护理文书占用时间,实现全程无缝隙的护理交接,提高了工作效率和医疗安全。

The character of day surgery includes shorter hospitalization time, kinds of surgery, quick turnaround, more intensive nursing workloads. The clinical procedure of day surgery is different from other departments. According to the character, we designed the clinical nursing record sheet and standardized the key point of shifting, decreased the document time, guaranteed the whole process and promoted the efficiency and medical quality.