表格式伤口护理记录单在伤口专科护理门诊的应用  

The application of tubular wound nursing records in wound specialist care clinic

作　　者：甘华秀[1] 朱瑶[1] 朱卉娟[1] 刘亚珍[1] 

机构地区：[1]南方医科大学珠江医院,广州市510282

出　　处：《护理实践与研究》2016年第8期55-57,共3页Nursing Practice and Research

摘　　要：目的:探讨表格式伤口护理记录单在伤口专科护理门诊的应用效果,规范专业内容,体现专业价值,提高工作效率。方法:根据相关法律法规,结合伤口专科护理内容,自行设计表格,经过临床试用并不断修改及完善后开始正试启用。结果:该表格在临床应用2年,临床应用效果满意。结论:专科护理记录单专科内容全面、记录简便,能客观、真实、连续、规范、全程体现患者门诊处理情况及伤口愈合过程,规避医疗风险,保证专科质量,可作为临床伤口专科及其他专科借鉴之用。Objective： To explore the applicative effects of tubular wound nursing records in wound specialist care clinic,regulate the professional content,reflect professional value and improve working efficiency. Methods： According to the related laws and regulations,combining wound specialist care content,the form was designed and started to be use officially after constant revision and perfection by clinical trial. Results： This form was applied in clinic for 2 years and the clinical applicative effect was satisfied. Conclusion： The content on specialty nursing record was completed and it was easily recorded,which can show the whole process of outpatient treatment and wound healing objectively,truly,continuously and normatively. The medical risk could be avoided and the specialty quality could be promised. The specialty nursing record could be used for reference to clinical wound specialty and other specialties.

关 键 词：伤口专科护理 护理记录 门诊病历 

分 类 号：R473[医药卫生—护理学]