临床护理记录规范化研究

Research on the Standardization of Clinical Nursing Record

目的设计一套简单、适用的临床护理表格 ,以达到《医疗事故处理条例》(下称《条例》)和《病历书写规范》(下称《规范》)对护理记录的要求。方法根据本院整体护理时期护理记录情况的分析结果 ,按照护理程序的 4个步骤 ,结合《条例》与《规范》的要求 ,设计一套临床护理记录表格及与其相配套的“书写规范及考核标准”、“护嘱项目指南”、“书写模板” ,并进行书写培训。结果新表格项目少、功能多、易操作 ,记录缺陷显著少于传统表格 (P <0 .0 1) ,且不降低护理质量及病人满意度。结论新表格简洁明了、易于记录 ,突出护理程序 ,体现计划护理 ,达到了住院病人全程记录及提高工效的目的。

Objective To design simple and suitable clinical nursing tables and administrative standards to meet the requests of nursing record, “medical accident handling regulations(regulations)” and “criterion of case history writing (criterion)”. Methods According to the requests of “regulations” and “criterion” in combination with the analysis of the holistic nursing in our hospital and four steps of nursing process,a set of clinical nursing tables was designed and matched with “the writing criterion and examination standards”, “items directory of the nurse’s advices” and “the writing models”. Results The new tables had fewer items so they were more simple and easier to use without decreasing the nursing quality and the degree of patients’ satisfaction.Nursing record defect in the new tables were fewer than those in the traditional table(P<0.01). Conclusion The new tables are simple, perspicuous and easy to record. The tables give prominence to the nursing procedure and cover the designing nursing.