骨科护理记录规范语言知识库的建立与临床应用效果评价  

Establishment of Orthodontic Nursing Record Standard Language Knowledge Base and Evaluation of Clinical Application Effect

作　　者：韦隆莉 孙其凤 邱岸梅 Wei Longli(Department of Orthopedics, University of Hong Kong Shenzhen Hospital, Shenzhen 518053)

机构地区：[1]香港大学深圳医院骨科

出　　处：《数理医药学杂志》2019年第7期1080-1082,共3页Journal of Mathematical Medicine

基　　金：深圳市科创委课题项目“基于国际护理实践分类的骨科标准化护理语言库的建立与探讨”编号:JCYJ20150331142757388

摘　　要：目的:观察分析骨科护理记录的现状,并建立规范语言知识库,探讨临床运用的效果。方法:抽取某院2014年6月~2015年6月的骨科住院病历共400份为对照组,抽取2015年8月~2016年8月的骨科住院病历共400份为观察组。对照组采用传统书写模式进行护理记录书写,观察组采用结构化模块方式,经建立护理记录规范语言知识库,规范护理书写流程,采用统一评分标准进行评分,对比两组护理记录的分数和质量。结果:观察组的护理记录得分高于对照组,对比差异具有统计学意义(P<0.05);观察组的护理记录质量高于对照组,对比差异具有统计学意义(P<0.05);观察组护理记录书写问题发生率少于对照组,对比差异具有统计学意义(P<0.05)。结论:规范骨科护理记录并建立规范语言知识库能有效地改善护理书写质量,临床运用的效果较佳,值得在临床中推广实施。Objective: To observe and analyze the status of orthopedic nursing record and establish a standardized language knowledge base, explore the effect of clinical application. Methods: A total of 400 orthopedic inpatient records from June 2014 to June 2015 in a hospital were selected as the control group. 400 patient’s records in the orthopedic hospital from August 2015 to August 2016 were selected as the observation group. The control group used the traditional writing mode for nursing records and writing, the observation group used the structured module mode. After establishing the knowledge base of nursing record specification language and standardizing nursing writing process, uniform scoring scale was used to compare the scores and quality of nursing records between the two groups. Results: The score of nursing record in observation group was higher than that in control group(P<0.05), and the difference was statistically significant. The quality of nursing record in observation group was higher than that of control group(P<0.05), and the difference was statistically significant. The incidence of nursing record writing problems in the observation group was less than that in the control group(P<0.05), and the difference was statistically significant. Conclusion: To standardize the record of orthopedic nursing and establish a standardized language knowledge base can effectively improve the quality of nursing writing. The effect of clinical application is better and it is worth of popularizing in clinical practice.

关 键 词：骨科 护理记录规范 知识库 

分 类 号：R473.6[医药卫生—护理学]