Clinical effect of simplifying the pattern of general patient care records

Abstract

Objective To investigate the general patient care record mode,in order to reduce the amount of writing and writing time.Methods 150 nurses were selected and investigated about their writing and nursing records to answer questionnaire in two periods.All nurses were divided into experimental group and control group by stratified,randomized,single-blind method.We chose them to be included in the standard case,on the basis of the control group,control group used the current writing requirements,experimental group used the simply writing requirement.Finally we evaluated the two groups by writing time and the quality of the two sets of records.Results The survey results showed the existing writing nursing records' satisfaction was significantly lower than the simplified care records' satisfaction (P＜0.01).The experimental results showed the differences of the time that groups first nursing records,the first nursing process record and discharged nursing records cost were significant (P＜0.01) and the differences of accuracy,completeness,timeliness,Chinese medicine dialectical nursing between data in the two groups of nursing records were significant (P＜0.05).Conclusions Compared with the control group,the experimental group simplifies the nursing records and physician repeated written content,can both comply with legal obligations and ensure the care and safety of principle,and really reduce the amount of nurses writing,shorten writing time,and improve working efficiency and satisfaction with nursing care. Key words: Simplify; Nursing records; Reduction; The amount of writing; Elevation; Satisfaction