优化手术室护理记录单提高护理文书书写质量探讨

Investigation on Optimizing Nursing Record Sheet in Operating Room to improve the Writing Quality of Nursing Documents

目的探讨手术室护理记录进行优化后,对护理文书质量的影响,以期提高护理记录的书写质量和效率。方法随机选取2018年2月1日-2021年1月31日在某院手术室进行手术的376例患者病案,采用信封法随机分为观察组和对照组各188例,对照组使用传统护理记录单进行书写,观察组使用优化后护理记录单进行书写,对两组护理记录书写质量进行质控,比较两组护理记录单书写缺陷发生率及填写效率。结果观察组患者护理记录单及时性100.00%、完整性100.00%和准确性99.47%均明显高于对照组的78.19%、73.94%和79.26%,χ^(2)=46.018、56.343、40.398,P<0.05,差异有统计学意义。观察组项目填写不全、书写错误或涂改、代签名、医护记录不一致、未使用医学术语等缺陷发生率均明显低于对照组,χ^(2)=4.748、9.400、8.174、6.454、6.528,P<0.05,差异有统计学意义。观察组记录耗时和累计填写字数均少于对照组,t=41.099、32.868,P<0.05,差异有统计学意义。结论优化手术室护理记录可减少书写缺陷,提高书写质量和效率,值得进一步推广应用。

Objectives To explore the effect of optimizing nursing records in operating room on the quality of nursing documents, so as to improve the writing quality and efficiency of nursing records. Methods A total of 376patients who underwent surgery in the operating room of a hospital from February 1st, 2018 to January 31st, 2021were randomly selected and divided into the optimization group and the control group by envelope method. The control group used the traditional nursing record sheet to record, and the optimization group used the optimization measures to deal with the nursing record sheet. The writing quality of the nursing record sheet of the two groups was compared. The incidence of writing defects and filling efficiency of nursing records were compared between the two groups. Results The single timeliness, completeness and accuracy of the patient care records in the optimization group were significantly higher than those in the control group(78.19%, 73.94% and 79.26%), with statistical significance(χ^(2)=46.018, 56.343 and 40.398, P<0.05). The incidence of writing defects in the optimization group was significantly lower than that in the control group(χ2=4.748, 9.400, 8.174, 6.454, 6.528, P<0.05).The incidence of writing defects in the optimization group was significantly lower than that in the control group(χ^(2)=4.748, 9.400, 8.174, 6.454, 6.528, P<0.05) The recording time and total number of words in the optimization group were significantly less than those in the control group, and the differences were statistically significant(t=41.099, 32.868, P<0.05).Conclusions Optimization of operating room nursing records could reduce writing defects and improve writing efficiency, which was worthy of further promotion and application.