临床护士对护理记录的认知状况调查

An Investigation on Cognition Status of Clinical Nurses to Nursing Records

目的 :了解华山医院临床护士对护理记录的认知状况。方法 :采用自制调查表对 3 0 0名病区和重症监护室护士进行调查。结果 :91.3 %护士认为护理记录很重要 ,5 2 .0 %护士未经过正规护理书写培训 ,仅2 4.3 %护士能适用恰当的方法收集病人资料 ,65 .7%护士认为没有充足的时间做护理评估。结论 :护理记录的重要性已被护士认识 ,但护士缺乏时间和部分护士不能运用恰当的评估方法。

Objective:to find out the cognition status of clinical nurses in Huashan hospital on nursing records. Method: 300 nurses from wards and intensive care units were investigated via filling out self-designed questionnaire. Results: 91.3% of nurses thought that nursing records were of importance. 52.0% of nurses had not got records writing training. Only 24.3% of them could collect cases data through proper ways. 65.7% of them thought that they had not enough time to undertake nursing evaluation. Conclusions: the importance of nursing records has already been recognized by most of the nurses. However, some nurses complained that they had not enough time to do it. Some nurses could not use proper method to evaluate it. Therefore, one should strengthen the writing skill training and adopt reasonable nursing evaluation scale to enhance the quality of nursing records.