三阶段护理记录模式在外科系统的应用与效果  

Application of three-phase nursing record model in Surgery Department

作　　者：柯巧芸[1] 曾招治[1] 刘玉芬[1] 

机构地区：[1]厦门市第二医院海沧医院外科,福建省361026

出　　处：《中国护理管理》2010年第6期66-68,共3页Chinese Nursing Management

摘　　要：目的:探讨三阶段护理记录模式对护士掌握书写护理记录的技巧,规范护理文件书写,提高护理质量的作用。方法:根据《福建省病历书写规范》要求设计了三阶段护理记录模式,并与常规的记录方式进行质量分析比较。结果:2008年1月采用三阶段记录模式后,病历质量检查分数明显提高(t=11.54,P<0.001);存在缺陷的护理病历明显减少(P<0.005);三阶段护理记录模式对护士掌握书写技巧和规范护理文件书写有较大帮助。结论:三阶段护理记录模式的应用,有利于护士掌握书写技巧,解决书写护理记录中存在的问题,提高护理文件书写的质量,同时也为质控标准的完善提供了依据。Objective： To explore the effect of implementing three-phase nursing record model. Methods： Based on the ＂Fujian Medical Record Standards＂, we designed three-phase nursing record model, then compared the record quality with the conventional methods. Results： Compared with the conventional methods, the total score of nursing document inspection improved （t= 11.54, P 〈0.001）; and the nursing documents with defect decreased （P 〈0.005） after implementing new methods. It was useful to help nurses to handle the nursing record skills and standardize the nursing document record process.Conclusion： The application of three-phase nursing record model could help nurses to master writing skills and overcome the problems in nursing record. Meanwhile, it would improve nursing document quality, and also provide a basis for improving quality control standards.

关 键 词：护理文件 记录模式 应用 

分 类 号：R47[医药卫生—护理学]