基于优质护理服务示范工程的护理文件书写表格化改进  

Modification of tabular nursing documentation based on high quality care demonstration project

作　　者：陈鸣明[1] 姜秀文[2] 张艺 杨东平 

机构地区：[1]上海市市东医院内分泌科,上海200438 [2]上海市市东医院护理部,上海200438 [3]上海市市东医院消化科,上海200438

出　　处：《护理学杂志》2011年第15期14-16,共3页

基　　金：上海市护理质量控制中心质量改进项目(2010QNQ09)

摘　　要：目的探讨护理文件书写表格化的改进方法及实施效果。方法根据卫生部优质护理服务示范工程的要求,以及有关护理文件书写的规定,设计一般护理记录单和危重护理记录单的表格式书写模式。在临床应用1年,跟踪调查统计书写时间,并自制问卷对表格式书写法进行评定。结果实施护理文件书写表格化改进后,118名护士书写1份新入院患者一般护理录和危重护理记录所需的时间显著少于实施前(均P<0.01);问卷17项内容测评结果显示表格式书写方式优于叙述式(P<0.05,P<0.01)。结论表格式护理文件书写方式能减少书写时间,把护理时间还于患者,在保证书写质量的同时,提高了护理质量。Objective To explore modification of tabular nursing documentation and its effect.Methods According to the high quality care demonstration program advocated by Department of Health and the provisions of nursing document,we designed a tabular presentation for general nursing documentation and critical care documentation and put it into practice for a year.The time needed by nurses to complete documentation was calculated and a homemade questionnaire was used to assess the effect.Results Totally,118 nurses spent less time in completing a copy of general nursing documentation for newly admitted patients and a copy of critical care documentation after the implementation of tabular documentation than before the implementation（P0.01 for all）.The 17-item questionnaire survey indicated better embracement of the new tabular presentation of nursing documentation by nurses than embracement of traditional descriptive one（P0.05,P0.01）.Conclusion Tabular nursing documentation shortens writing time,which ensures the quality of nursing writing and improves the quality of nursing.

关 键 词：优质护理服务示范工程 护理文件 表格式 一般护理记录单 危重护理记录单 改进 

分 类 号：R472[医药卫生—护理学] C931.4[医药卫生—临床医学]