CAJ | 학술논문

目的：制作简单实用的特情记录卡，及时了解患者的病情，方便工作人员随时记录患者的一些特殊情况，使交班内容简单明了。方法在我院两个病区使用，每个在班护士随身携带，班班交班。结果开展特情记录卡前的110例住院患者中，交班患者数8（7.3%）例，开展特情记录卡后108例住院患者中，交班患者数32（29.6%）例；开展前交班症状数3.6项，开展后交班症状数5.6项。结论使用特情记录卡后，科室护士每人都能随时观察，随时记录，保证了病情观察及时、全面、真实性、连贯性。
목적：제작간단실용적특정기록잡，급시료해환자적병정，방편공작인원수시기록환자적일사특수정황，사교반내용간단명료。방법재아원량개병구사용，매개재반호사수신휴대，반반교반。결과개전특정기록잡전적110례주원환자중，교반환자수8（7.3%）례，개전특정기록잡후108례주원환자중，교반환자수32（29.6%）례；개전전교반증상수3.6항，개전후교반증상수5.6항。결론사용특정기록잡후，과실호사매인도능수시관찰，수시기록，보증료병정관찰급시、전면、진실성、련관성。
Objective:to make simple and practical managing record card, timely understanding of the patient's condition, some special cases to facilitate staf at any time record of patient, make shift simple content. Methods: in my hospital two wards, each nurse to carry in the class, class shift. Results: the development of special records of 110 hospitalized patients were card in front of the number of patients, including 8 (7.3%), to carry out special record card after 108 hospitalized patients, including 32 (29.6%) were carried out before the handover symptoms; 3.6, carry out after the 5.6 handover symptoms. Conclusion: with the use of emergency nurses record card, everyone can observe, record which ensure timely, comprehensive observation, authenticity, coherence.