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目的通过对产科护理记录单进行有效的设计改进,从而提高产科护理记录质量。方法调查产科护理记录单的现状,分析存在问题的原因,根据实际情况对产科护理记录单进行设计改进。随机抽取护理记录单改进前后的产科终末护理记录单各360份进行质量评分,并对护理表格设计改进前后的护士满意度和护理终末病案质量评分进行比较。结果护理记录单设计改进后较改进前产科护理终末病案质量评分有显著提高(P<0.05),产科护理人员满意度也明显提高(P<0.05)。结论产科护理记录单的设计改进能够提高护理人员的工作效率,有效的提高产科护理终末病案书写质量。
OBJECTIVE To improve the quality of obstetric nursing records through effective design and improvement of obstetric care records. Methods Investigate the status quo of Obstetrics Nursing Records and analyze the causes of the problems. According to the actual situation, design and improve Obstetrics Nursing Records. A total of 360 records of obstetrics and gynecology nursing records before and after the improvement of nursing records were randomly selected to evaluate the quality of nursing records. Nurses’ satisfaction and the quality of nursing final medical records were compared before and after the improvement of nursing table design. Results After the design of the nursing record sheet was improved, the score of the final medical record of obstetric care was significantly improved (P <0.05) and the satisfaction of obstetric nursing staff was also significantly improved (P <0.05). Conclusions The design of obstetrics nursing record sheet can improve the work efficiency of nursing staff and effectively improve the writing quality of obstetric nursing end disease record.