半结构化护理记录在取卵术后护理中的应用  

Application of Semi-Structured Nursing Records in Post-Oocyte Retrieval Nursing Care

作　　者：陈丽云 邹雅琴 Chen Liyun;Zou Yaqin(Medical Center for Human Reproduction,Beijing Chaoyang Hospital,Capital Medical University,Beijing 100020,China;不详)

机构地区：[1]首都医科大学附属北京朝阳医院生殖医学中心,北京市100020

出　　处：《中国病案》2025年第3期20-22,共3页Chinese Medical Record

摘　　要：目的探讨在取卵术后护理中应用半结构化护理记录的效果,以及通过完善护理记录提高取卵术后护理效率。方法随机选取某三甲医院生殖医学中心2023年3月1日—2023年9月30日进行取卵的患者103例患者为对照组,2023年11月1日—2024年4月30日进行取卵的患者104例患者为观察组,对照组采用术后传统护理记录方式,观察组使用半结构化护理记录方式,并将2组在不同角度进行比较,包括书写时间、书写质量、护士使用满意度、不良事件发生,应用t检验和χ^(2)检验等统计分析。结果观察组术后入院护理记录平均用时(157.18±29.64)秒、术后离院前出院记录平均用时(100.54±14.53)秒、交接班记录平均用时(123.54±15.53)秒、各类风险评估平均用时(151.31±15.96)秒,均少于对照组(172.19±52.93)、(107.46±13.66)、(198.81±15.43)、(188.74±22.31)秒,差异具有统计学意义;观察组术后风险评估单得分(33.15±1.35)分,术后护理记录单得分(37.74±1.56)分,体温单得分(23.21±1.48)分高于对照组(32.61±1.47、36.75±1.75、22.74±1.61)分,2组比较差异具有统计学意义。护士对取卵术后采用半结构化的护理记录后的整体满意度为94.8%,各条目均分(4.74±0.17)分。结论半结构化护理评估的方法在取卵术护理上应用具有高效、快捷的特点,可有效提高护士工作效率和工作质量。Objectives This study aims to clarify the effect of applying semi-structured nursing records in post-oocyte retrieval care,and to improve the efficiency of post-oocyte retrieval care by improving nursing records.Methods A total of 103 patients who underwent oocyte retrieval from March 1,2023 to September 30,2023 in the Reproductive Medicine Center of a tertiary hospital were randomly selected as the control group,and 104 patients who underwent oocyte retrieval from November 1,2023 to April 30,2024 were randomly selected as the observation group.The control group adopted the traditional postoperative nursing record method,and the observation group adopted the semi-structured nursing record method.The two groups were compared in different aspects,including writing time,writing quality,nurses'satisfaction with the use of the product,and the occurrence of adverse events.Results The average time taken for postoperative admission nursing record in the observation group was(157.18±29.64)seconds,the average time taken for postoperative discharge record was(100.54±14.53)seconds,the average time taken for handover record was(123.54±15.53)seconds,and the average time taken for various risk assessments was(151.31±15.96)seconds,which were all less than those in the control group(172.19±52.93,107.46±13.66,198.81±15.43,and 188.74±22.31 seconds,respectively),and the difference was statistically significant.The postoperative risk assessment score(33.15±1.35),postoperative nursing record score(37.74±1.56),and temperature score(23.21±1.48)in the observation group were higher than those in the control group(32.61±1.47,36.75±1.75,and 22.74±1.61),and the difference between the two groups was statistically significant.The overall satisfaction of nurses with the semi-structured nursing record after oocyte retrieval was 94.8%,and the average score of each item was(4.74±0.17).Conclusions The semi-structured nursing assessment method is efficient and fast in oocyte retrieval nursing,which can effectively improve the work eff

关 键 词：半结构化护理记录 取卵术 护理管理 

分 类 号：R473.71[医药卫生—护理学]