重症监护室护理记录单的设计与应用

目的 探讨新ICU护理记录单的临床应用效果。方法 分析总结原ICU护理记录单存在内容少、重点不突出、量化内容不具体，缺乏完整性和规范性的缺陷，重新设计ICU护理记录单，并对ICU护士进行相关培训。结果 ICU护理记录表格临床运用1年来，记录表格完整、清晰，记录及时准确，改进后ICU护理记录单书写质量显著优于改进前（均P〈0．01）。结论 ICU护理记录单符合形势发展需要，具有法律意识，客观而真实地记录危重患者痛情和信息，提高了护理文书的书写和护理管理质量。

Design and Application of A New Nursing Record Sheet in ICU

Objective To investigate the effect of a new ICU nursing record sheet in clinical practice.Methods In view of the weaknesses of old nursing record sheets,which are not informative enough,fail to focus on important items,and are less quantitative,not complete and not standardized.A quality control panel was set up and the experts of the panel revised the old sheets after much deliberation and designed a new nursing record sheet which took current contexts,legal issues and practicality into account.Nurses were trained in the use of the new sheet.Results The new sheet has been clinically used for one year and all the information of the patients was clearly,completely and accurately recorded in a timely way.The quality of sheet-recording for ICU nursing service was significantly better than that before the revision(P<0.01 for all).Conclusion The new ICU nursing record sheet can help to improve the quality of the sheet-writing and nursing service.