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引用本文:应波 张晓蕾 陈曦 常红 尉俊铮.症状引导下结构化护理记录的临床应用与效果评价[J].中国护理管理,2017,17(5):641-645 本文二维码信息
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症状引导下结构化护理记录的临床应用与效果评价
The application of the symptom-guided structured nursing records
  
DOI:10.3969/j.issn.1672-1756.2017.05.016
中文关键词:  规范化培训  症状  结构化  临床转化
English Keywords:standardized training  symptom  structured  clinical conversion
基金项目:
作者单位
应波 张晓蕾 陈曦 常红 尉俊铮 首都医科大学宣武医院护理部100053 北京市(应波陈曦)神经外科(张晓蕾)神经内科(常红)信息中心(尉俊铮) 
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中文摘要:
      目的:构建以症状观察为主线的结构化护理记录,使新护士通过规范化培训获得的症状护理技能实现同步临床应用。方法:依据规范化培训工作思路,在结合培养教材、查阅文献与相关书籍的基础上设计症状引导下的结构化护理记录,通过专家咨询和试用体验完善护理记录框架,并引入移动护理系统,分析症状引导下结构化护理记录使用后规范化培训护士及带教老师的满意度。结果:规范化培训护士及带教老师应用后的使用体验满意度分别为91.81%和84.44%,无统计学差异(P>0.05),护理记录勾选写入时间明显低于手工录入时间,有统计学差异(P<0.05)。结论:症状引导的结构化护理记录的设计与应用完成了从规范化培训到临床实际工作的零缝隙衔接,是教、学、实践三位一体的有益尝试,不但提高了护理记录书写效率,同时体现不同学科疾病特点,适用于综合医院不同临床科室,展现了护理工作内涵。
English Summary:
      Objectives: To set up an observed symptom-guided structured nursing records system for new nurses' training. Methods: According to the requirement of the standardized training, the authors designed the symptoms-guided nursing records system based on literature review. After experts consulting and pilot application, they introduced it to the mobile nursing information system. And then they analyzed the satisfaction of the new nurses and the teachers who used this system to train new nurses. Results: The satisfaction of new nurses and teachers were 91.81% and 84.44%, respectively (P>0.05). The time spending on the observed symptom-guided structured nursing records online was significantly lower than the manual entry time (P<0.05). Conclusion: The observed symptom-guided structured nursing records system applied in new nurses' training linked standard training with clinical practice without interruption, minimized the conversion cycle from learning to practice. It could improve the recording efficiency of nurses; and reflect the disease characteristics of different disciplines.
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