表格式转运护理文书在区域性新生儿转运网络中的应用

Application of Tabular Transport Nursing Documents in Regional Neonatal Transport Network

目的探讨表格式转运护理文书在新生儿转运网络中护理文书书写质量及转运安全的应用效果,为新生儿转运中应用表格式护理文书的可行性提供参考。方法随机抽取2015年1月1日-2019年12月31日通过新生儿转运网络入院的病例共2000份进行回顾性分析。以表格式转运护理文书书写的1000份病例作为研究组,以常规护理文书书写的1000份转运护理病案作为对照组;比较2组病例中新生儿转运病案建立时间,书写缺陷例次以及转运中的护理纠纷隐患和不良事件的发生率。结果研究组转运病案建立时间(14.56±3.08)较对照组(23.64±4.05)分钟缩短,P<0.001。研究组护理文书漏签名、生命体征或病情描述记录不一致、实施治疗护理措施后无反馈结果、书写口语化、随意涂改等缺陷140例次,低于对照组的897例次,均P<0.001。研究组转运过程中护理安全隐患STABLE评估缺项和与转诊医院病情描述不一致的发生率分别为1.4%、0.9%,低于对照组的3.8%、7.8%;护理安全隐患皮肤破损发生率、导管脱出或移位的发生率分别为1.2%、0.4%,低于对照组的3.1%、1.9%,均P<0.05。结论表格式转运护理文书能缩短转运病案建立时间,减少书写缺陷、降低潜在的护理纠纷隐患和不良事件的发生率,促进新生儿转运安全。

Objective To explore the application effect of tabular nursing documents in the writing quality and safety of nursing documents in neonatal transport network,and to provide reference for the feasibility of using tabular nursing documents in neonatal transport network.Methods A total of 2000 cases admitted through the neonatal transport network from January 1,2015 to December 31,2019 were randomly selected for retrospective analysis.1000 cases of transshipment nursing documents written in form form were taken as the study group,and 1000 cases of transshipment nursing records written in routine nursing documents were taken as the control group.The establishment time of neonatal transport medical records,the number of writing defects,the incidence of nursing disputes and adverse events in the transport were compared between the two groups.Results The establishment time of transport records in the study group was shorter(14.56±3.08 minutes)than that in the control group(23.64±4.05 minutes),P<0.001.In the study group,there were 140 cases of missing signature of nursing documents,inconsistency of vital signs or condition description,no feedback results after the implementation of treatment and nursing measures,oral writing,and random alteration,which were lower than 897 cases in the control group,all P<0.001.In the study group,the incidence of missing items of STABLE assessment of nursing safety risks and inconsistency with the description of conditions in the referral hospital were 1.4%and 0.9%,respectively,which were lower than 3.8%and 7.8%in the control group.The incidence of skin damage and catheter prolapse or displacement were 1.2%and 0.4%,respectively,which were lower than 3.1%and 1.9%in the control group,both P<0.05.Conclusions The tabular transport of nursing documents could shorten the establishment time of transport medical records,reduce writing defects,reduce the incidence of potential nursing disputes and adverse events,and promote the safety of newborn transport.