事项清单联合SOAP交班模式在全科医学科的应用  

Application of task list combined with the Subjective Objective Assessment Plan(SOAP)format in nurse shift handover in the general medicine department

作　　者：金环 王玉梅[2] 彭雯[2] 康静[2] 游婷[2] 肖甜 王丽君[2] Jin Huan;Wang Yumei;Peng Wen;Kang Jing;You Ting;Xiao Tian;Wang Lijun(General Medicine Department,Union Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan 430022,China)

机构地区：[1]华中科技大学同济医学院附属协和医院护理部,湖北武汉430022 [2]华中科技大学同济医学院附属协和医院全科医学科,湖北武汉430022

出　　处：《护理学杂志》2024年第17期67-71,共5页Journal of Nursing Science

基　　金：华中科技大学教学研究项目(2023125);华中科技大学同济医学院第一临床学院教学改革研究项目(202146)。

摘　　要：目的探讨事项清单联合SOAP交班模式在全科医学科床边交班中的应用效果。方法构建事项清单联合主观-客观-评价-计划(SOAP)结构化交班模式,用于全科医学科患者床边交接班;比较交班模式改进前(587例次的传统口头交班)、后(605例次的事项清单联合SOAP交班)的床边交班效果、交班缺陷情况。结果交班模式改进后护士床边交接班效果显著优于改进前、交班缺陷率显著降低(均P<0.05)。结论采用事项清单联合SOAP交班模式行患者床边交班,可提高床边交班质量,有利于保障患者护理安全。Objective To explore the effect of task list in combination with the SOAP format in nurse shift handover in the general medicine department.Methods A standardized task list was developed for intershift handover and the SOAP format was used for handover of critically ill patients.The quality and errors in shift handover were compared between 587 cases using purely verbal handover style and 605 cases using the novel handover style.Results The quality of shift report was significantly enhanced,whereas errors were significantly decreased after implementation of the novel handover shift style(all P<0.05).Conclusion The application of task list combined with the SOAP format for nurse shift handover can improve bedside handover quality and ensure patient safety.

关 键 词：全科医学科 护理交班 床边交班 主观-客观-评价-计划 事项清单 清单管理 患者安全 护理管理 

分 类 号：R47[医药卫生—护理学] C931.2[医药卫生—临床医学]