CAJ | 학술논문

目的：探讨围手术期护理记录单的设计及应用效果。方法自行设计围手术期护理记录单并应用于外科，比较改进前后书写时间及护理人员对表单的效果评价。结果改进后36名护士书写同病种围手术期护理记录单时间少于改进前，护理文件质量评分高于改进前，护士对围手术期护理记录单的节约书写时间、内容全面、重点突出、记录客观准确、具有书写提示性方面的满意度评分均高于改进前，差异有统计学意义（P ＜0．05）。结论围手术期护理记录单的应用有利于简化护理文件书写，规范护理执业行为，提高工作效率和节约护士书写时间。
목적：탐토위수술기호리기록단적설계급응용효과。방법자행설계위수술기호리기록단병응용우외과，비교개진전후서사시간급호리인원대표단적효과평개。결과개진후36명호사서사동병충위수술기호리기록단시간소우개진전，호리문건질량평분고우개진전，호사대위수술기호리기록단적절약서사시간、내용전면、중점돌출、기록객관준학、구유서사제시성방면적만의도평분균고우개진전，차이유통계학의의（P ＜0．05）。결론위수술기호리기록단적응용유리우간화호리문건서사，규범호리집업행위，제고공작효솔화절약호사서사시간。
Objective To explore the design and application effects of a modified perioperative nursing records .Methods A modified perioperative nursing record was self -designed and applied to surgical wards .The record time and effect evaluation by nurses were compared before and after modification .Results After modification,the perioperative nursing records on the same diseases of 36 nurses had less record time and higher record quality when compared to before modification (P <0.05).The results of the evaluation questionnaires from five out of six nurses demonstrated that the design was better than before modification (P <0.05).Conclusion The application of the modified perioperative nursing records can standardize the nursing practice ,enhance the efficiency of work and improve the quality of nursing records.