门诊宫腔镜检查手术护理记录单的设计及应用  

Design and application of nursing record sheet for hysteroscopy operation in outpatient department

作　　者：黄莹[1] 章燕梅 唐朝亮 殷艳 HUANG Ying;ZHANG Yan-mei;TANG Chao-liang(The First Affiliated Hospital of USTC,University of Science and Technology of China,Hefei 230001,Anhui)

机构地区：[1]中国科学技术大学附属第一医院,安徽合肥230001

出　　处：《安徽医专学报》2022年第4期20-21,68,共3页Journal of Anhui Medical College

基　　金：湖北陈孝平科技发展基金会资助项目(编号:CXPJJH12000005-07-115)。

摘　　要：目的:探讨门诊宫腔镜检查手术护理记录单的设计及应用效果。方法:根据门诊宫腔镜检查操作流程和护理特点,设计具有专科特色的手术护理记录单,包括5部分:患者基本信息、术前评估、麻醉实施前再次核查、术中病情观察、术后关注要点及签名,记录单内容以填空或勾选方式填写。结果:手术护理记录单内容全面、条目清晰,体现专科特色,能准确、高效评估患者情况,正确核对患者身份,确认术前准备齐全,明确术中观察重点及术后交接,对关键内容不遗漏,减少差错事故的发生。结论:手术护理记录单可规范护士操作行为及护理文书书写质量,有利于护士及时、准确、全面地记录门诊宫腔镜检查患者在手术室的护理情况,有效保存法律依据。Objective:To explore the design and application effect of nursing record sheet for hysteroscopy in outpatient department.Methods:According to the operation process and nursing characteristics of hysteroscopy in outpatient department,a nursing record sheet with special features was designed,which included five parts:basic information of patients,preoperative evaluation,rechecking before anesthesia,observation during operation,key points after operation and signature.The record sheet was completed by filling in blank or checking.Results:The operation nursing record sheet was comprehensive in content and clear in items,reflecting the specialty characteristics,which can accurately and efficiently evaluate the patient's condition,correctly check the patient's identity,confirm the complete preparation before operation,clarify the key points of observation during operation and the handover after operation,not omit the key contents,and reduce the occurrence of errors and accidents.Conclusion:The operation nursing record sheet can standardize the nurses'operation behavior and the writing quality of nursing documents,which is beneficial for nurses to record the nursing situation of patients undergoing hysteroscopy in the operating room timely,accurately and comprehensively,and effectively preserve the legal basis.

关 键 词：门诊 宫腔镜检查 手术安全 记录单 

分 类 号：R47[医药卫生—护理学]