中医表格式护理记录单的设计和使用.pdfVIP

2008年7月 护 理 管 理 杂 志 Jul，2008 第8卷7期 Journal of Nursing Administration V01．8 N0．7 ·47· 中医表格式护理记录单的设计和使用 卿晓堂，梁凤仙 (新疆医科大学附属中医医院护理部，新疆 乌鲁木齐 830000) 摘要：目的 探讨一般患者中医表格护理记录单的设计方法和使用效果。方法 自行设计中医表格式护理记录单，将1 186例患者分为两组， 每组593例，实验组采用中医表格式护理记录单，对照组采用文字式护理记录单，观察两组完成记录所用的时间及中医护理要点记录完整性的 差异。结果 实验组完成记录所用时间少于对照组，中医护理要点记录的完整性高于对照组(P0．叭)。结论 中医表格式护理记录能缩短 记录书写时间，提高工作效率，能较全面地反映中医护理观察要点，体现中医护理特色。 关键词：中医护理；护理表格设计；护理记录单 中图分类号：C931．2 文献标识码：B 文章编号：1671—315X(2008)07—0047—02 The design and application of nu~ing record form in Traditional Chinese Medicine／QING Xiao—tang．LIANG Feng—xian／／Journal of Nuts- ing Administration，一2008，8(7)：47． Abstract：Objective To explore the designed method and evaluate the application of nursing records form in Traditional Chinese Medicine．Method A nursing records form in Traditional Chinese Medicine was designed and applied in 593 patients．While the nursing records for the other 593 patients in con‘ trol group were recorded with literal description means．Then，the time and quality of nursing records were compared between the two groups．Result Com· pared with the control group．the time was shorter and the quality of nursing records was significantly better in the experimental group(P0．叭 )． Conclusion The application of nursing records form in Traditional Chinese Medicine can shorten the time of nursing recording，improve work efficiency， fully reflect the key points of nursing observations and embody the features of Traditional Chinese Medicine． Author’S address：Nursing Department，Affiliated Hospital of Traditional Chinese Medicine，Xinjiang Medical University，Urumchi 830000，China Key words：Traditional Chinese Medicine nursing；nursing form design；nursing records 护理记录是依据《医疗事故处理条例》的实施而产生的 院首次护理记录；②入院护理过程记录；③出院护理记录。 一 种新型医疗文件，具有十分重要的法律意义 j