眼耳鼻喉科表格式护理记录单的设计制作与应用  

Design and Application of Tabular Nursing Records Chart on Ophathamology and Otolaryngology Department

作　　者：席淑新[1] 张琼[1] 单蓉[1] 黄皛梦[1] 

机构地区：[1]复旦大学附属眼耳鼻喉科医院护理部,上海200031

出　　处：《解放军护理杂志》2010年第18期1430-1432,共3页Nursing Journal of Chinese People's Liberation Army

摘　　要：目的自行设计并应用眼耳鼻喉科表格式护理记录单,探讨提高眼耳鼻喉科专科护理记录效率和质量的方法。方法以护理表格"护理化"、体现专科特色、避免重复记录、简单易行等原则,对眼耳鼻喉科的一般护理记录单、危重护理记录单和手术护理记录单进行再设计,所有记录单的内容均以外科护理常规与眼耳鼻喉科专科评估、观察和护理项目相结合,书写方法基本以打勾和填空为主。结果新的表格式专科护理记录单大大节省了护理记录的时间,提高了护理文件书写质量和临床护理质量,体现了专科特色,得到了临床护士的认可。结论采用突出专科特色的表格式护理记录单,既能提高护理人员的工作效率,又能提高护理质量,有利于保证患者安全。Objective To improve the efficiency and quality of Eye ENT department nursing records with self-designed single table format of eye care records of Eye ENT department.Methods General eye care sheets,record sheets and surgical critical nursing records of Eye ENT department were re-designed according to the principles of nursing centered format,specialized features,avoidance of duplicate records and simplicity.The contents of all the forms were designed by combing surgical conventional nursing,specialized assessment of Eye ENT,observation and nursing programs.The basic writing methods mainly involved ticking and filling in the blanks.Results The new nursing records sheets decreased the time consumed in recording nursing procedure significantly,improved the quality of nursing and nursing records,showed the specialized characteristics of nursing of Eye ENT,which were accepted by clinical nurses.Conclusion The new table format with highlight of special features of the nursing records can enhance the efficiency of nursing staff,improve the nursing quality and help ensure patients＇ safety.

关 键 词：眼耳鼻咽喉科 护理记录 表格式设计 

分 类 号：R473.76[医药卫生—护理学]