摘要
目的:分析双面表格护理记录单应用过程中的质量缺陷及改进对策。方法:选取2015年1月-2016年12月病历1000份(对照组)及2017年1月-2018年12月病历1000份(观察组)。对2000份双面表格护理记录单中表格正面已设置好“专科观察项目”栏的填写质量及根据病情需要责任护士增添“临时观察项目”,表格背面“特殊情况”栏内容的记录质量3类项目进行检查;并调查收集医护人员对表格应用满意度、每天书写表格时间、年轻护士专业水平提高情况。结果:观察组表格正面专科观察项目填写质量、临时观察项目预置准确全面例次及表格背面特殊情况记录栏内容填写质量均高于对照组,差异有统计学意义(P<0.05);观察组医护人员对双面表格应用的满意度、护士书写表格时间及年轻护士专业知识提高方面均优于对照组,差异有统计学意义(P<0.05)。结论:双面表格护理记录单更能体现护理记录内涵,保证患者安全,值得临床推广应用。
Objective:To analyze quality defects and improvement measures of application process of double-sided form nursing record sheet.Methods:From January 2015 to December 2016,1000 medical records on shelf were selected as control group and from January 2017 to December 2018,1000 medical records were selected as observation group.The quality of the"specialty observation project"column has been set and the responsible nurse needed to add a"temporary observation project"according to the medical condition.The quality of the records in the"special circumstances"column on the back of the form was checked for three types of items,the application of the form by the medical staff was investigated and collected satisfaction,time to write forms every day and the improvement of the professional level of young nurses.Results:The quality of the filling of the specialty observation items on the front of the observation group and the presets of the temporary observation items were accurate and comprehensive.The quality of the content of the special situation record column on the back of the form was higher than that of the control group,the differences were statistically significant(P<0.05).Conclusion:The double-sided nursing record form can better reflect the connotation of nursing records and ensure the safety of patients,which is worthy of clinical application.
作者
方丽芬
黄玉如
黄少娅
Fang Lifen;Huang Yuru;Huang Shaoya(Nursing Department,the People's Hospital of Puning City,Guangdong Puning 515300)
出处
《中国社区医师》
2020年第36期130-131,共2页
Chinese Community Doctors
关键词
双面表格护理记录单
质量缺陷
对策
Double-sided form nursing record sheet
Quality defects
Countermeasures
