摘要
目的建立实用的手术室介入护理记录指标体系,为提高护理记录质量提供改进依据。方法某科于2023年5月1日开始实施护理记录指标体系,按照随机数表法,分别选取2022年5月1日—2023年4月30日、2023年6月1日—2024年5月31日收治的各140例手术室介入治疗患者作为实施前组和实施后组,比较护理记录指标体系实施前后护理记录书写合格率、护理记录缺陷发生情况和护理意外事件发生率,并比较护理记录指标体系实施前后护理人员对护理记录的满意程度。结果护理记录指标体系实施后护理记录要素质量合格率97.14%、环节质量合格率98.57%和终末质量合格率95.00%均高于实施前(85.00%,86.42%,82.86%),P<0.05,差异具有统计学意义;护理记录指标体系实施后护理记录缺陷发生率5.00%明显低于实施前16.43%,P<0.05,差异具有统计学意义;护理记录指标体系实施后护理人员满意度100.00%明显高于实施前80.00%,P<0.05,差异具有统计学意义。结论手术室介入护理治疗记录指标质量评价体系的应用可提高护理记录书写合格率,减少缺陷发生率和护理意外发生率,护理人员满意度高。
Objectives This study aims to establish a practical evaluation system for the quality of interventional nursing records in operating room,and to provide a basis for improving the quality of nursing records.Methods Starting from May 1,2023,a nursing documentation indicator system was implemented in a certain department.Using a random number table method,140 patients who underwent interventional treatment in the operating room from May 1,2022 to April 30,2023 and another 140 patients from June 1,2023 to May 31,2024 were selected as the pre-implementation group and post-implementation group,respectively.The study compared the qualified rate of nursing documentation,the occurrence of documentation defects,and the incidence of nursing adverse events before and after the implementation of the indicator system.It also compared the satisfaction level of nursing staff with nursing documentation before and after the system was implemented.Results"After the implementation of the nursing documentation indicator system,the qualification rates of documentation element quality(97.14%),process quality(98.57%),and final quality(95.00%)were all significantly higher than those before implementation(85.00%,86.42%,and 82.86%,respectively),with P<0.05,indicating statistically significant differences.The incidence of documentation defects after implementation(5.00%)was significantly lower than before(16.43%),P<0.05,also showing statistical significance.Furthermore,the satisfaction rate of nursing staff with documentation after implementation reached 100.00%,significantly higher than the pre-implementation rate of 80.00%,P<0.05,again indicating statistical significance.Conclusions The establishment of an index quality evaluation system for interventional nursing records in the operating room can improve the qualified rate of nursing record writing,reduce the incidence of defects and nursing accidents,and the nursing staff's satisfaction is high.
作者
高雅
刘晓楠
易晓平
霍晓川
李晶
Gao Ya;Liu Xiaonan;Yi Xiaoping;Huo Xiaochuan;Li Jing(Operating Room,Beijing Tiantan Hospital,Capital Medical University,Beijing 100070,China;不详)
出处
《中国病案》
2025年第7期7-10,共4页
Chinese Medical Record
关键词
手术室
介入治疗
护理记录
指标体系
Operating room
Interventional therapy
Nursing records
Index system
