CAJ | 학술논문

目的探讨表格式护理记录书写指南在五官科的应用效果.方法对照组资料选定2007年10月～2009年2月在我科住院的120例病人的护理记录,实验组资料选定2009年3月～2010年5月在我科住院的120例病人的护理记录,两组病人的护理记录均采用我科自行设计表格式护理记录,对照组护理记录由责任护士常规记录,实验组护理记录组织学习并应用表格式护理记录书写指南由责任护士进行记录.结果应用表格式护理记录书写指南前后,两组护理记录书写质量比较,经统计学分析,P值均＜0.05,差异具有统计学意义.结论应用表格式护理记录书写指南来指导临床护士书写护理记录是可以保证书写的完整性、及时性、动态性和规范性,从而提高了表格式护理记录的书写质量.
목적 탐토표격식호리기록서사지남재오관과적응용효과.방법 대조조자료선정2007년10월～2009년2월재아과주원적120례병인적호리기록,실험조자료선정2009년3월～2010년5월재아과주원적120례병인적호리기록,량조병인적호리기록균채용아과자행설계표격식호리기록,대조조호리기록유책임호사상규기록,실험조호리기록조직학습병응용표격식호리기록서사지남유책임호사진행기록.결과 응용표격식호리기록서사지남전후,량조호리기록서사질량비교,경통계학분석,P치균＜0.05,차이구유통계학의의.결론 응용표격식호리기록서사지남래지도림상호사서사호리기록시가이보증서사적완정성、급시성、동태성화규범성,종이제고료표격식호리기록적서사질량.
Objective To study the effect of the writing guideline of tabular nursing records in otolaryngology department.Methods There were two groups,each group of 120 nursing records.Experimental group was finished between October 2007 to February 2009,and control group was finished between March 2009 to May 2010.Nursing records of each group were recorded by self-designed table.Control group was taken regularly by the nurses on duty,experiment group was taken by the nurses who had been trained applying the writing guideline of the nursing records.Results The qualities of nursing records writing were compared between before and after applying the writing guideline of tabular nursing records as well as two groups,there were statistical differences (P ＜0.05).Conclusions The writing guideline of nursing records can guarantee the integrity,effectiveness,dynamic characteristics and specification of nursing notes taking,as well as promote the quality of itselt.