CAJ | 학술논문

目的减少护士书写时间,使护理记录科学化、规范化和简洁化,提高护理措施落实率.方法设计一套符合实际的神经外科表格式护理记录单,并与综述式护理记录单应用情况进行比较.结果每位护士平均书写每份护理记录的时间由10.85 min降至2.99 min;经统计学处理(P＜0.001),差异有统计学意义.另外,表格式护理记录组书写表格的整洁度、记录及时性及护理措施的正确和到位率与综述式护理记录组比较(P＜0.01)差异有统计学意义.结论神经外科表格式护理记录单的设计符合表格设计的要求,操作简便,极大地减少了护士书写时间.更注重护理措施的落实,使病人得到更全面、准确的护理.
목적 감소호사서사시간,사호리기록과학화、규범화화간길화,제고호리조시락실솔.방법 설계일투부합실제적신경외과표격식호리기록단,병여종술식호리기록단응용정황진행비교.결과 매위호사평균서사매빈호리기록적시간유10.85 min강지2.99 min;경통계학처리(P＜0.001),차이유통계학의의.령외,표격식호리기록조서사표격적정길도、기록급시성급호리조시적정학화도위솔여종술식호리기록조비교(P＜0.01)차이유통계학의의.결론 신경외과표격식호리기록단적설계부합표격설계적요구,조작간편,겁대지감소료호사서사시간.경주중호리조시적락실,사병인득도경전면、준학적호리.
Objective To make the nursing records scientific,standard and succinet,seve the dascriping time and raise the performance rate of nursing process.Methods To redasigu a new bind of form which was fit for form'nursing records of neurosurgery.And compare it with the summary of single-care record groups.Results The mean time used in writing nursing records was decreased from 10.85 minutes per nurse per nursing record to 2.99 minutes.Moreover,The form of nursing record groups was improved in the form the entire fineness,record timeliness and the nursing measure correct and the arriving rate than the summary of single-care record groups.(P＜0.001).Conclusions The form'nursing records in neumsurgery form conforms to the request of form designing.And it's simple to use.Soit savas the time in writing nursing records.Also,it puts the nursing intervention into effect.Then the patients can get holistic care..