甲基强的松龙冲击治疗护理记录单的设计与应用  

Design and application of nursing recording sheet for methylprednisolone ictus treatment

作　　者：赵小学[1] 张春燕[1] 

机构地区：[1]中国医学科学院北京协和医学院北京协和医院风湿免疫科,100032

出　　处：《中华现代护理杂志》2013年第9期1089-1090,共2页Chinese Journal of Modern Nursing

摘　　要：目的自行设计并应用甲基强的松龙冲击治疗护理记录单，探讨提高专科护理记录的效率和质量的方法。方法以护理表格体现专科特色、避免重复记录、简单及易行等原则，记录单内容与内科护理常规和免疫专科评估、观察和护理项目相结合，书写方法基本以打勾和填空为主。结果新的护理记录单在很大程度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。结论采用突出专科特色的护理记录单，既能提高护理人员的工作效率，又能提高护理质量，有利于保证患者的安全。Objective To design and apply nursing recording sheet for methylprednisolone ictus treatment, and study methods to improve efficiency and quality of nursing record. Methods In order to show specialist characteristics, avoid duplicate record and achieve simplicity, contents of recording sheet were combined with conventional nursing in department of medicine, immune specialist evaluation, observation and nursing projects. Writing methods were basically ticking and filling the blanks. Results New nursing recording sheet could save nursing record time as well as improved the quality of nursing documents and clinical nursing, which reflected specialist characteristics. Conclusions Nursing recording sheet with specialist characteristics can improve both nurses＇ working efficiently and nursin~ quality, which heh）s to ensure oatients＇ safety.

关 键 词：护理记录 表格 设计 甲基强的松龙冲击治疗 

分 类 号：R47[医药卫生—护理学]