【摘要】 目的:通过设计与评价首次与出院护理记录表的应用效果,探索简化护理记录、缩短间接护理时间的措施。方法:从我院抽取护士600名随机分为对照组和实验组各300例,分别采用传统的非表格式的护理记录书写方式和自行设计的首次与出院护理记录表完成记录。比较两组护士的护理记录质量评分及书写记录所耗用的时间。结果:实验组护理记录质量评分比对照组明显提高,书写记录时间缩短。两组比较具有统计学差异(P<0.01)。结论:首次与出院护理记录表的应用,能够缩短书写护理记录的时间,简化护理记录,提高护理质量。更多还原

【Abstract】 Objective: To explore the strategy to simplify nursing record and shorten indirect nursing time through designing and using the nursing record chart of admission and discharge. Methods: We sampled 600 nurses from our hospital and divided them into two groups, 300 nurses in each group. The nurses in experimental group implemented the new nursing record chart method. Meanwhile, the nurses in control group used traditional method. Then we compared the nursing record quality and time to write them. Results: Nurses in experimental group got higher nursing record quality score and spent less time to write them than control group (P <0.01). Conclusion: The application of nursing record chart of admission and discharge could reduce the time in writing nursing record, simplify nursing document and improve nursing care quality.更多还原