优化护理记录书写的方法及效果  

Investigation on methods and effects of optimizing nursing documents

作　　者：王玉娟[1] 钱嘉晖[2] 程芳[1] 

机构地区：[1]首都医科大学电力教学医院护理部,北京100073 [2]首都医科大学电力教学医院干部病房,北京100073

出　　处：《中华现代护理杂志》2013年第35期4392-4395,共4页Chinese Journal of Modern Nursing

摘　　要：目的探讨优化护理记录的方法及应用效果。方法随机选取50名护士，在优化护理记录前后进行问卷调查，调查书写护理记录的时间、对护理记录的理解程度以及填写过程中患者的配合程度。结果优化后，88％的护士书写时间在30min以内，高于优化前的62％，差异有统计学意义（X2=9．013，P〈0．05）；优化后，80％的护士表示完全理解所写记录，高于优化前的60％，差异有统计学意义（X2=4．762，P〈0．05）。优化后，80％的护士认为在填写护理记录过程中患者的配合程度提高，高于优化前的60％，但差异无统计学意义（x2=3．154，P〉0．05）。结论优化护理记录可缩短护士书写时间，提高护士对护理记录的理解程度，并提高填写过程中患者的配合程度。Objective To explore the methods of optimizing nursing documents and evaluate its effects. Methods Fifty nurses selected by random sampling were surveyed by a questionnaire. The questionnaire was distributed before and after nursing documents was optimized. The time of writing for nursing documents, nurses＇ understanding of the nursing documents and the degree of patients＇ cooperation in filling documents were compared. Results Before nursing documents optimized, 62% nurses＇ writing time was in thirty minutes.After optimized, 88% nurses＇ writing time was in thirty minutes and less than before （ x2 = 9. 013, P 〈 0.05）. 80% Nurses expressed that they had good understanding of nursing documents, higher than before and statistically significant （x2 = 4. 762, P 〈 0.05 ）, and the degree of patients＇ cooperation improved, but there was no statistical significance （x2 = 3. 154,P 〉 0.05 ）. Conclusions Optimizing nursing documents can shorten the time of documents writing, improve nurses＇ understanding of nursing documents and patients＇ cooperation in filing documents.

关 键 词：护理记录 护理 效果 

分 类 号：R47[医药卫生—护理学]