耳鼻咽喉口腔科表格式护理记录单的设计与应用  

The disign and application of nursing recording table of the otolaryngology and stomatology deparment

作　　者：许倩茹[1] 王华珍[2] 林小玲[1] 徐彬妮[1] 

机构地区：[1]广东医学院附属医院五官科,广东湛江524001 [2]广东医学院附属医院护理部,广东湛江524001

出　　处：《国际护理学杂志》2009年第10期1306-1308,共3页international journal of nursing

基　　金：湛江市科技攻关项目（湛科2008年52号）

摘　　要：目的探讨自行设计的耳鼻咽喉口腔科表格式护理记录单的实用性、科学性。方法将280例病人随机分为实验组（140例）和对照组（140例）。实验组采用耳鼻咽喉口腔科表格式护理记录单书写护理记录；对照组采用传统的护理记录单叙述式书写护理记录，书写内容为人院后首次、术后首次护理记录。比较两组（单份病历）书写记录平均耗用时问及书写质量。结果实验组书写护理记录的平均耗用时间少于对照组（P〈0．001），实验组书写质量方面明显优于对照组（P〈0．001）。结论使用耳鼻咽喉口腔科表格式护理记录单既能够缩短书写护理记录的时间，又能保证护理记录质量，提高了护理工作效率。Objective To summarize the practicality and rationality of nursing recording table of the Otolaryngology and Stomatology Deparment, which was designed by myself. Methods There were two groups （ each of which had 140 people） ： experimental and control groups. Two nurses who were in charge took nurses＇notes by using the nursing recording table in experiment group, while the same two nurses took nurses＇notes by using traditional nursing recording to narrate in control group. Results The mean time of taking notes in experimental group was less than that of control group （P 〈0. 001 ）, and the file＇s quality was better in experimental group （ P 〈 0. 001 ） . Conclusions Nursing recording table could decrease the time using In taking notes, improve the file＇s quality, application ifine.

关 键 词：表格式 护理记录 耳鼻咽喉口腔科 设计与应用 

分 类 号：R472[医药卫生—护理学]