CAJ | 학술논문

目的探讨床边表格式护理记录模式在儿科病区的临床应用效果。方法按责任护士分管的床位分为观察组185例和对照组194例。两组责任护士新收患儿的工作内容一致，观察组的表格式护理记录由责任护士在床边完成，对照组的表格式护理记录由责任护士在护士站完成。比较两组护理表格式护理记录的缺漏数。结果两组表格式护理记录缺漏份数、患儿家属对健康教育掌握率比较，差异有统计学意义。结论在床边进行表格式护理记录较在护士站表格式护理记录准确、及时、避免了不必要的医疗纠纷发生，减少了护理记录的缺漏发生率。
목적탐토상변표격식호리기록모식재인과병구적림상응용효과。방법안책임호사분관적상위분위관찰조185례화대조조194례。량조책임호사신수환인적공작내용일치，관찰조적표격식호리기록유책임호사재상변완성，대조조적표격식호리기록유책임호사재호사참완성。비교량조호리표격식호리기록적결루수。결과량조표격식호리기록결루빈수、환인가속대건강교육장악솔비교，차이유통계학의의。결론재상변진행표격식호리기록교재호사참표격식호리기록준학、급시、피면료불필요적의료규분발생，감소료호리기록적결루발생솔。
Objective Discuss the application of bedside sheet format nursing record patterns in pediatric ward. Methods Dividing the nurses into observation group (with 185 cases) and contrast group (with 194 cases) according to the responsible bed. The working of two groups is same. The sheet format nursing records of the observation group are finished bedside;while those of the contrast group are finished at nurse station. Compare the defect rate of the records, the mastery rate of patient dependent to health education and the satisfy rate of patient dependent to the nurses. Results The difference of defect rate, mastery rate and satisfy rate between the two groups has statistical significance. Conclusion Bedside sheet format nursing record is more accurate and timely than which is finished at the nurse station, and can avoid some unexpected dispute.