CAJ | 학술논문

目的对重症监护室原有的护理记录单进行改进,使其更全面细致地反映重症监护室病人的病情变化和护理过程,减少护士记录时间.方法在我院原重症监护护理记录单的基础上,增加了监护项目、用英文缩写字母或数字代替文字记录.结果经过1年的培训、应用和完善,重症监护室的护士已经全部掌握了记录方法,缩短了记录时间.结论新版<重症监护护理记录单>,达到了记录的便捷与高效,使及时记录得以落实,减轻了书写工作量,使护士有更多的时间和精力为患者提供直接护理服务.
목적 대중증감호실원유적호리기록단진행개진,사기경전면세치지반영중증감호실병인적병정변화화호리과정,감소호사기록시간.방법 재아원원중증감호호리기록단적기출상,증가료감호항목、용영문축사자모혹수자대체문자기록.결과 경과1년적배훈、응용화완선,중증감호실적호사이경전부장악료기록방법,축단료기록시간.결론 신판<중증감호호리기록단>,체도료기록적편첩여고효,사급시기록득이락실,감경료서사공작량,사호사유경다적시간화정력위환자제공직접호리복무.
Objective To reflect the condition of ICU patients in the process of care and to reduce the recording time of nurses. Methods Based on our former hospital intensive care nursing records, more care items and the abbreviation letters or numbers instead of written records were included. Results After a year of training, application and details of the changes, intensive care unit nurses have all mastered the recording methods, and recording time was reduced. Conclusions The new version of "intensive care nursing records" was convenient and efficient;records can be implemented in time, workload of writing was reduced, so that nurses have more time and energy to provide direct care services to patients.