CAJ | 학술논문

目的比较实时性护理记录和总结性护理记录内涵的缺陷情况.方法分别抽查实时性护理记录和总结式护理记录病历390份,比较两组护理记录书写在及时性、准确性、真实性、连贯性、内容不重复方面存在的问题.结果实时性护理记录缺陷病历的发生率低于总结性护理记录缺陷病历的发生率(P<0.01);实时性护理记录内涵在书写欠及时、欠准确、欠真实、欠连贯、记录内容重复方面存在的问题明显少于总结性护理记录(P<0.05).结论实时性护理记录书写方式减少护理记录内涵缺陷的发生率,提高护理记录内涵的质量方面优于总结性护理记录书写方式.
목적 비교실시성호리기록화총결성호리기록내함적결함정황.방법 분별추사실시성호리기록화총결식호리기록병력390빈,비교량조호리기록서사재급시성、준학성、진실성、련관성、내용불중복방면존재적문제.결과 실시성호리기록결함병력적발생솔저우총결성호리기록결함병력적발생솔(P<0.01);실시성호리기록내함재서사흠급시、흠준학、흠진실、흠련관、기록내용중복방면존재적문제명현소우총결성호리기록(P<0.05).결론 실시성호리기록서사방식감소호리기록내함결함적발생솔,제고호리기록내함적질량방면우우총결성호리기록서사방식.
Objective To evaluate and compare content defects of real-time and summary nursing records. Methods 390 pieces of real-time nursing records and 390 pieces of summary nursing records were randomly reviewed. The defects of contents in timeliness, accuray, authenticity, continuity,and repetition were compared between the two groups. Results The group with real-time nursing records had a lower defect rate than the group with summary nursing records (P<0.01). Real-time records had fewer defects in timeliness, accuracy, authenticity, continuity, and repetition than summary records (P< 0.05). Conclusions The way of real-time writing nursing records can reduce the occurrence of content defects and is superior to that of summary writing in improving the quality of nursing record.