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目的调查上海地区医院护理文书使用的现况,为规范区域性标准化护理文书提供依据。方法采用自行设计的《上海地区医院护理文书现况调查问卷》,选取上海地区29所医院的护理文书使用现况进行调查分析。结果体温单、入院护理评估单、一般护理记录单、转运交接单、压疮风险评估单及跌倒/坠床风险评估单是各医院最基本的护理文书(100%),其中体温单、入院护理评估单为目前常用的电子护理文书(>90%)。体温单、医嘱单、手术护理记录单等护理文书在急诊留观室、急诊抢救室和日间病房的使用情况波动较大(13.8%~79.3%),责任护士每日护理书写时间为30~90 min(34.5%~37.9%)。结论上海地区医院护理文书使用现状存在一定差距,电子护理文书有待进一步开发与利用,需构建标准化护理文书,进一步规范护理文书书写。
Objective To investigate the current situation of the use of hospital nursing instruments in Shanghai and provide the basis for standardizing regional standardized nursing instruments. Methods The self-designed “Questionnaire on the Status of Hospital Nursing Documents in Shanghai” was used to investigate the status of nursing documents in 29 hospitals in Shanghai. Results The list of body temperature, admission nursing assessment, general nursing record, transfer order, pressure ulcer risk assessment form and fall / fall risk assessment sheet were the most basic nursing documents in each hospital (100%), including single temperature, admission nursing The evaluation sheet is the most commonly used electronic nursing instrument (> 90%). (13.8% -79.3%) of the nursing documents such as body temperature list, doctor’s order form and surgical nursing record list were widely used in emergency room, emergency room and daytime ward. The daily nursing writing time of responsible nurses was 30 ~ 90 min (34.5% -37.9%). Conclusion There is a certain gap in the current status of hospital nursing instruments in Shanghai. Electronic nursing instruments need to be further developed and utilized. Standardized nursing instruments need to be established to further standardize the writing of nursing instruments.