专科化巡回记录单在手术室中的设计与应用效果分析  

Design and application effect analysis of specialized operation nursing records in operating room

作　　者：孔雪婷 叶红梅 陈荣珠 KONG Xue-ting;YE Hong-mei;CHEN Rong-zhu(The First Affiliated Hospital of the University of Science and Technology of China(Anhui Provincial Hospital),Hefei 230001,Anhui)

机构地区：[1]中国科学技术大学附属第一医院(安徽省立医院)手术室,安徽合肥230001

出　　处：《安徽医专学报》2025年第1期12-14,共3页Journal of Anhui Medical College

摘　　要：目的:探讨专科化巡回记录单在手术室中的设计与应用。方法:整合不同专科手术常用收费耗材,制作专科化巡回记录单,选择2023年6月-12月在医院行6类手术的600例患者,采用随机信封法分为观察组300例,对照组300例。观察组采用专科化巡回记录单,对照组采用传统巡回记录单。比较两组巡回记录单护士填写用时、巡回记录单填写差错率及手术室护士对两种记录单的满意度评分。结果:观察组填写用时均小于对照组,差异有统计学意义(P<0.01);观察组中漏填、填写与实际不符、字迹不清、医学术语不规范等填写差错率均低于对照组,差异有统计学意义(P<0.01);手术室护士对专科化巡回记录单的书写便利、条目清晰、内容详细、完整及体现专科水平得分和总分均高于传统巡回记录单,差异有统计学意义(P<0.01)。结论:应用专科化巡回记录单能够减少手术室护士填写记录单时间,降低记录单填写差错率,提高手术室护士满意度。Objective:To explore the design and application of specialized itinerant record sheet in the operating room.Methods:To integrate the commonly used charging materials of different specialized operations and make specialized tour record sheets.From June to December 2023,600 patients who underwent the six types of operations in hospital were randomly divided into observation group(300 cases)and control group(300 cases)by envelope method.The observation group was treated with the specialized itinerant record sheet,The filling time,error rate and satisfaction scores of nurses in the operating room were compared between the two groups.Results:The filling time of the observation group was shorter than that of the control group,and the difference was statistically significant(P<0.01);Compared with the control group,the error rates of missing filling,inconsistent filling,illegible writing and non-standard medical terminology in the observation group were significantly lower(P<0.01).The operating room nurses'writing convenience,clear entries,detailed and complete contents,the scores reflecting the specialty level and the total scores of the specialized tour record sheet were higher than those of the traditional tour record sheet,and the difference was statistically significant(P<0.01).Conclusion:The application of specialized itinerant record sheet can reduce the time for nurses in operating room to fill in the record sheet,reduce the error rate of record filling and improve the satisfaction of nurses in operating room.

关 键 词：专科化巡回记录单 手术室 记录单 应用效果 

分 类 号：R197.323[医药卫生—卫生事业管理]