CAJ | 학술논문

目的：探讨管床医生与责任护士联合查房对医护记录、护理级别、患者满意度的影响。方法选择本院泌尿外科作试点科室，2014年3—5月387例住院患者采用传统查房模式进行查房（传统查房组），2014年6—8月412例住院患者采用管床医生与责任护士联合查房的模式进行查房（联合查房组），通过质控运行病历并记录医护记录不一致情况；评估患者病情和生活自理能力并与护理级别对照；进行满意度调查。结果联合查房组较传统查房组医护记录不一致明显减少（P<0.05），护理级别准确率明显提高（P<0.01），患者满意度提高（P<0.05）。结论管床医生与责任护士联合查房可有效减少医护记录不一致现象，护理级别更准确，提高患者满意度。
목적：탐토관상의생여책임호사연합사방대의호기록、호리급별、환자만의도적영향。방법선택본원비뇨외과작시점과실，2014년3—5월387례주원환자채용전통사방모식진행사방（전통사방조），2014년6—8월412례주원환자채용관상의생여책임호사연합사방적모식진행사방（연합사방조），통과질공운행병력병기록의호기록불일치정황；평고환자병정화생활자리능력병여호리급별대조；진행만의도조사。결과연합사방조교전통사방조의호기록불일치명현감소（P<0.05），호리급별준학솔명현제고（P<0.01），환자만의도제고（P<0.05）。결론관상의생여책임호사연합사방가유효감소의호기록불일치현상，호리급별경준학，제고환자만의도。
Objective To explore the effect of joint ward-round of doctors with nurses on medical records and patients ’ satisfaction. Methods Conventional ward-round was conducted among 387 patients in Urology Department from March to May 2014 and joint ward-round of doctors with nurses was performed among 412 patients from June to August 2104. Medical records between doctors ’ and nurses’ and patients’ satisfaction were compared after different types of ward-round. ResuIts Significant decrease was observed in the disagreements between doctors’ and nurses’ records (P<0.05); the correct rate of nursing level identification (P<0.01) and patients’ satisfaction were improved (P<0.05). ConcIusion Joint ward-round of doctors and nurses benefits the decrease of disagreement between doctors’ and nurses’ record, the appropriate identification of nursing level and the improvement of patients’ satisfaction.