CAJ | 학술논문

目的：探讨优化护理记录的方法及应用效果。方法随机选取50名护士，在优化护理记录前后进行问卷调查，调查书写护理记录的时间、对护理记录的理解程度以及填写过程中患者的配合程度。结果优化后，88％的护士书写时间在30 min以内，高于优化前的62％，差异有统计学意义（χ2＝9．013，P＜0．05）；优化后，80％的护士表示完全理解所写记录，高于优化前的60％，差异有统计学意义（χ2＝4．762，P＜0．05）。优化后，80％的护士认为在填写护理记录过程中患者的配合程度提高，高于优化前的60％，但差异无统计学意义（χ2＝3．154，P＞0．05）。结论优化护理记录可缩短护士书写时间，提高护士对护理记录的理解程度，并提高填写过程中患者的配合程度。
목적：탐토우화호리기록적방법급응용효과。방법수궤선취50명호사，재우화호리기록전후진행문권조사，조사서사호리기록적시간、대호리기록적리해정도이급전사과정중환자적배합정도。결과우화후，88％적호사서사시간재30 min이내，고우우화전적62％，차이유통계학의의（χ2＝9．013，P＜0．05）；우화후，80％적호사표시완전리해소사기록，고우우화전적60％，차이유통계학의의（χ2＝4．762，P＜0．05）。우화후，80％적호사인위재전사호리기록과정중환자적배합정도제고，고우우화전적60％，단차이무통계학의의（χ2＝3．154，P＞0．05）。결론우화호리기록가축단호사서사시간，제고호사대호리기록적리해정도，병제고전사과정중환자적배합정도。
Objective To explore the methods of optimizing nursing documents and evaluate its effects . Methods Fifty nurses selected by random sampling were surveyed by a questionnaire .The questionnaire was distributed before and after nursing documents was optimized .The time of writing for nursing documents , nurses’ understanding of the nursing documents and the degree of patients ’ cooperation in filling documents were compared.Results Before nursing documents optimized, 62%nurses’ writing time was in thirty minutes.After optimized, 88%nurses’ writing time was in thirty minutes and less than before (χ2 =9.013, P<0.05). 80% Nurses expressed that they had good understanding of nursing documents , higher than before and statistically significant (χ2 =4.762,P<0.05), and the degree of patients ’ cooperation improved, but there was no statistical significance (χ2 =3.154,P>0.05).Conclusions Optimizing nursing documents can shorten the time of documents writing , improve nurses ’ understanding of nursing documents and patients ’ cooperation in filing documents .