一体化护士工作站中新生儿病房首次护理评估单的设计与应用

Design and Application of the First Nursing Assessment Form for the Neonatal Ward in the Integrated Nurse Workstation

目的:探讨一体化护士工作站升级后新生儿病房首次护理评估单的应用效果。方法:将入院评估单、危险因素评估单、健康教育记录单、自理能力评估单整合到一单,观察实施3个月后的效果。结果:升级后的新生儿病房首次护理评估单,使护理人员用于入院评估的时间明显缩短,护理文书的书写质量明显提升。结论:一体化护士工作站升能后的新生儿病房首次护理评估单设计合理,操作步骤简化,节省了护士首次评估时间,减少了评估时的遗漏,值得临床推广应用。

Objective： To discuss about the application effect of the first nursing assessment form for the neonatal ward in the integrated nurse workstation. Methods： Adlnission assessment form, risk factor assessment form, health education record from and self care ability assessment form are integrated into a titan. The effect after 3 months of implementation is observed, Results： After the improvement of the first nursing assessment form for the neonatal ward, the time of admission assessment of nursing startS; is significantly shortened, and the writing quality of nursing documents is improved significantly. Conclusion： After the improvement, the first nursing assessment form for the neonatal ward in the integrated nurse workstation has a reasonable design and simplified operation steps, saves the first assessment time for nurses, and reduces omissions in assessment. It is worthy of clinical popularization and application.