围术期电子护理记录单对胃肠外科护士书写质量的影响

Effect of Perioperative Electronic Nursing Record Sheet on Writing Quality of Nurses in Gastrointestinal Surgery

目的设计应用围术期电子护理记录单,研究其对胃肠外科护士书写能力的影响。方法随机选取2017年6月1日-2017年12月31日在某院胃肠外科手术患者45份护理记录单为对照组,随机选取2018年1月1日-2018年12月31日在某院胃肠外科手术患者45份护理记录单为观察组。对照组按照常规护理记录单形式进行书写,观察组采用电子护理记录单进行记录,比较对照组与观察组护理记录单书写质量。结果观察组围术期护理记录单书写时效性(100%)、完整性(100%)及正确性(96%)均显著高于对照组(77.78%、80%、82.22%)(P<0.05)。观察组围术期护理记录单重复记录(17.78%)、出入量记录不规范(15.56%)、缺乏连续性及动态性(15.56%)、空白项目(15.56%)、记录表述不清及不客观(8.89%)、发生率均显著低于对照组(2.00%、0.00%、2.00%、2.00%、0.00%)(P<0.05)。结论围术期电子护理记录单系统能够减少书写缺陷,提高书写质量。

Objective The perioperative electronic nursing record sheet was designed and applied to study its effect on the writing ability of gastrointestinal surgical nurses. Methods Forty-five nursing records of patients undergoing gastrointestinal surgery in a hospital from June 1, 2017 to December 31, 2017 were randomly selected as the control group, and 45 nursing records of patients undergoing gastrointestinal surgery in a hospital from January 1, 2018 to December 31, 2018 were randomly selected as the observation group. The control group was written in the form of routine nursing record sheet, while the observation group was recorded with electronic nursing record sheet, and the writing quality of nursing record sheet was compared between the control group and the observation group. Results The timeliness, completeness and correctness of perioperative nursing record writing in the observation group(100%, 100%, 96%) were significantly higher than those in the control group(77.78%, 80%, 82.22%)(P<0.05). In the observation group, the repetitive records of perioperative nursing records(17.78%), non-standard input and output records(15.56%), lack of continuity and dynamics(15.56%), blank items(15.56%), unclear and objective records(8.89%), and the incidence rate were significantly lower than those in the control group(2.00%, 0.00%, 2.00%, 2.00%, 0.00%)(P<0.05). Conclusion Perioperative electronic nursing record sheet system can reduce writing defects and improve writing quality.