CAJ | 학술논문

目的简化一般患者护理记录的模式,减少书写量,节省书写时间.方法选择参与书写护理记录的护士共150人分两个时间段进行问卷调查;运用分层、随机、单盲的方法将150名参与书写护理记录的内、外科护士分为实验组和对照组,选择纳入标准病例,在使用表格式护理记录单的基础上,对照组实施现行的书写要求,实验组实施简化的书写要求,对两组记录从书写时间和质量方面进行测评分析.结果问卷调查结果显示:现行书写护理记录的满意度明显低于简化护理记录的满意度(P＜0.01).实验结果显示:两组的第一次护理记录,一次的护理过程记录,出院护理记录所用的时间差异有统计学意义(P＜0.01);两组护理记录中监测数据的准确性、完整性、及时性、中医辩证施护内容比较差异有统计学意义(P＜0.05).结论简化护理记录中与医师重复书写的内容,既遵行法律责任和保证护理安全的原则,又真正减少护士的书写量,缩短书写时间,提高工作效率和护理服务的满意度.
목적 간화일반환자호리기록적모식,감소서사량,절성서사시간.방법 선택삼여서사호리기록적호사공150인분량개시간단진행문권조사;운용분층、수궤、단맹적방법장150명삼여서사호리기록적내、외과호사분위실험조화대조조,선택납입표준병례,재사용표격식호리기록단적기출상,대조조실시현행적서사요구,실험조실시간화적서사요구,대량조기록종서사시간화질량방면진행측평분석.결과 문권조사결과현시:현행서사호리기록적만의도명현저우간화호리기록적만의도(P＜0.01).실험결과현시:량조적제일차호리기록,일차적호리과정기록,출원호리기록소용적시간차이유통계학의의(P＜0.01);량조호리기록중감측수거적준학성、완정성、급시성、중의변증시호내용비교차이유통계학의의(P＜0.05).결론 간화호리기록중여의사중복서사적내용,기준행법률책임화보증호리안전적원칙,우진정감소호사적서사량,축단서사시간,제고공작효솔화호리복무적만의도.
Objective To investigate the general patient care record mode,in order to reduce the amount of writing and writing time.Methods 150 nurses were selected and investigated about their writing and nursing records to answer questionnaire in two periods.All nurses were divided into experimental group and control group by stratified,randomized,single-blind method.We chose them to be included in the standard case,on the basis of the control group,control group used the current writing requirements,experimental group used the simply writing requirement.Finally we evaluated the two groups by writing time and the quality of the two sets of records.Results The survey results showed the existing writing nursing records' satisfaction was significantly lower than the simplified care records' satisfaction (P＜0.01).The experimental results showed the differences of the time that groups first nursing records,the first nursing process record and discharged nursing records cost were significant (P＜0.01) and the differences of accuracy,completeness,timeliness,Chinese medicine dialectical nursing between data in the two groups of nursing records were significant (P＜0.05).Conclusions Compared with the control group,the experimental group simplifies the nursing records and physician repeated written content,can both comply with legal obligations and ensure the care and safety of principle,and really reduce the amount of nurses writing,shorten writing time,and improve working efficiency and satisfaction with nursing care.