围手术期护理记录单的设计与应用效果

Design and Application Effect of Nursing Records in the Perioperative Period

目的:探讨围手术期护理记录单的智能设计与应用效果。方法:按照围手术期护理记录单各个版块进行逐项核查交接,排除隐患。并对书写时间及护士满意度与改进前进行比较。结果:围手术期护理记录单规范了手术各个环节的交接内容,保证了工作的连续性,避免差错事故的发生;并在书写时间及护士满意度方面差异均具有统计学意义(P<0.05)。结论:智能设计后的围手术期护理记录单提高了护理工作效率,提升了护理服务质量,保证了患者安全。

Objective： To explore the intelligent design and application effect of nursing records in the perioperative period. Methods： According to each section of the nursing records of perioperative period, each item is checked and handed over, and the hidden trouble is eliminated. Writing time and nurse satisfaction are compared with that before the improvement. Results： The nursing records of perioperative period standardize the handover content of each link of operation, ensure the continuity of work and avoid errors; and the difference in writing time and nurse satisfaction is statistically significant（P0.05）. Conclusion： The nursing records of the perioperative period after intelligent design improve the nursing work efficiency and the nursing service quality and ensure the safety of patients.