眼科表格式护理记录单的设计和应用  

Design and application of tabular nursing records sheet in ophthalmology department

作　　者：郭谊楠[1] 许乐[1] 刘月芬[1] 李永霞[1] 王清[1] 

机构地区：[1]福建医科大学附属协和医院眼科,福州市350001

出　　处：《中华护理教育》2012年第12期559-561,共3页Chinese Journal of Nursing Education

摘　　要：目的设计眼科适用的表格式护理记录单,并探讨其应用效果。方法结合眼科特色和临床路径,设计眼科表格式护理记录单,并同期使用新旧两种护理记录单,对109例住院病例的护理记录进行差异性比较。结果表格式护理记录单节省了书写时间(P<0.01),提高了护理文件书写质量(P<0.01)。护士对表格式护理记录单给予充分肯定,认可度和满意度达100%。结论表格式护理记录单结合专科特色和临床路径,既规范准确、重点突出、内容全面,又减少书写时间,提高护理记录质量和工作效率。Objective To design a tabular nursing records sheet which is suitable for ophthalmology department and evaluate its effects. Methods The tabular nursing records sheet was designed according to the specialized features of ophthalmology department and the clinical pathway. The application effects were compared between the new and old forms among 109 patients. Results The new tabular nursing records sheet decreased the time consumed in writing nursing records and improved the quality of nursing records. The nurses accepted the tabular nursing records sheet easily and nurses＇ acceptance and satisfaction rate was 100%. Conclusion The tabular nursing records sheet with highlight of specialized features of ophthalmology department and the clinical pathway,not only is standard,accurate,focused,and comprehensive,but also can improve the quality and efficiency of nursing work.

关 键 词：眼科学 护理记录 表格和记录管理 

分 类 号：R47[医药卫生—护理学]