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ICU护理记录单的优化设计及临床应用
引用本文:黄颖琼,许叶华,曾霞,杨文亮,冯吉.ICU护理记录单的优化设计及临床应用[J].中华护理杂志,2011(10).
作者姓名:黄颖琼  许叶华  曾霞  杨文亮  冯吉
作者单位:610072, 成都市 四川省人民医院EICU
摘    要:目的 优化ICU护理记录单,减少护士护理记录书写量,连续、动态、客观反映患者病情变化,提高临床护理工作质量.方法根据科室特点设计表格、文字书写相结合的记录单,并与原ICU护理记录单比较.结果新旧两种护理记录单在记录信息量、书写耗费时间上的差异均有统计学意义(P<0.05).结论优化后的ICU护理记录单书写时间明显减少,记录信息量更大,书写质量显著提高,护士业务水平不断提升.

关 键 词:重症监护病房:  护理记录  表格和记录管理

Optimal design and clinical application of nursing records sheet in ICU
HUANG Ying-qiong,XU Ye-hua,ZENG Xia,YANG Wen-Hang,FENG Ji.Optimal design and clinical application of nursing records sheet in ICU[J].Chinese Journal of Nursing,2011(10).
Authors:HUANG Ying-qiong  XU Ye-hua  ZENG Xia  YANG Wen-Hang  FENG Ji
Institution:HUANG Ying-qiong,XU Ye-hua,ZENG Xia,YANG Wen-liang,FENG Ji
Abstract:Objective To optimize ICU nursing records sheet and explore an optimal way for nursing records which is time saving,convenient and suitable for continuous ICU monitoring.Methods A new ICU nursing records sheet was designed intergrated with tables and notes.The information and writing time were compared between the new nursing records sheet and the former one.Results Compared with the former nursing records sheet,the writing time was reduce and the information was increased in the new nursing records sheet(P...
Keywords:Intensive Care Units  Nursing Records  Forms and Records Control  
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