CAJ | 학술논문

目的：探讨个案追踪检查法结合护士长点评在临床护理查房中的应用效果。方法选择2012年1～12月在本院住院患者300例设为对照组，采用传统护理查房模式；2013年1～12月在本院住院的患者330例设为观察组，采用个案追踪法结合护士长点评查房模式。比较病区护理管理质量（包括病房管理、分级护理、基础护理、护理安全、健康教育）及护理文书合格率情况。结果两组病区护理管理质量及护理文书合格率比较，均P＜0．05，差异具有统计学意义，观察组护理管理质量及护理文书合格率明显高于对照组。结论个案追踪检查法结合护士长点评提高临床护理查房质量，同时有效提高护士综合素质及护士长管理水平。
목적：탐토개안추종검사법결합호사장점평재림상호리사방중적응용효과。방법선택2012년1～12월재본원주원환자300례설위대조조，채용전통호리사방모식；2013년1～12월재본원주원적환자330례설위관찰조，채용개안추종법결합호사장점평사방모식。비교병구호리관리질량（포괄병방관리、분급호리、기출호리、호리안전、건강교육）급호리문서합격솔정황。결과량조병구호리관리질량급호리문서합격솔비교，균P＜0．05，차이구유통계학의의，관찰조호리관리질량급호리문서합격솔명현고우대조조。결론개안추종검사법결합호사장점평제고림상호리사방질량，동시유효제고호사종합소질급호사장관리수평。
Objective To explore the effect of case checking and head nurses′ comment on clinical nurisng rounds. Methods Three hundred hospitalized patients from January to December of 2012 were set as the control group , which received the traditional nursing ward round model. Another three hundred and thirty patients hospitalized from January to December of 2013 were set as the observation group, which received case tracking method integrated with head nurses ward round model. The ward nursing management quality of both groups including the ward management, grading nursing, basic nursing, nursing safety, health and education and the qualified rate of nursing documents were compared between the two groups. Result The quality of nursing management and nursing documents qualification rate of the observation group were obviously higher than those of the control group. Conclusion The case tracking method and the head nurses′comments can improve the quality of clinical nursing rounds , enhance nurses comprehensive quality and increase management level of the head nurses.