PDF下载

[1]刘雄涛刘儒忠张静李棪臻张林娟边冬梅师文崔雅清刘清元李姗李豪古茹孔德玲赵丽燕杨惠云.陕西省标准化手术护理记录单构建研究[J].中国卫生质量管理,2025,32(12):46-50.[doi:10.13912/j.cnki.chqm.2025.32.12.10]
　LIU Xiongtao,LIU Ruzhong,ZHANG Jing.Research on the Construction of a Standardized Surgical Nursing Record Form in Shaanxi Province[J].Chinese Health Quality Management,2025,32(12):46-50.[doi:10.13912/j.cnki.chqm.2025.32.12.10]

点击复制

陕西省标准化手术护理记录单构建研究

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 32 期数: 2025年12期页码: 46-50 栏目: 护理质量出版日期: 2025-12-15

Title:: Research on the Construction of a Standardized Surgical Nursing Record Form in Shaanxi Province

作者:: 刘雄涛刘儒忠张静李棪臻张林娟边冬梅师文崔雅清刘清元李姗李豪古茹孔德玲赵丽燕杨惠云; 西安交通大学第二附属医院

Author(s):: LIU Xiongtao; LIU Ruzhong; ZHANG Jing; The Second Affiliated Hospital of Xi’an Jiaotong University

关键词:: 手术室; 护理记录单; 护理文书; 护理质量

Keywords:: Operating Room; Nursing Record Form; Nursing Documentation; Nursing Quality

分类号:: R47

DOI:: 10.13912/j.cnki.chqm.2025.32.12.10

文献标志码:: A

摘要:: 目的构建陕西省标准化手术护理记录单，促进手术室护理同质化管理。方法基于文献回顾，初步确立记录单框架、内容及要点；通过问卷调查，收集各医疗机构使用的护理记录单，识别存在问题，完善记录单内容；采用德尔菲法，确定标准化手术护理记录单。结果标准化手术护理记录单包含术前、术中、术后和物品清点四大核心模块，同时明确了填写注意事项。结论手术护理记录单符合陕西省地域特点，将逐步推广应用。

Abstract:: ObjectiveTo develop a standardized surgical nursing record form for Shaanxi Province to promote homogeneous management of nursing care in operating rooms. MethodsBased on a literature review, the initial framework, content, and key points of the record form were established. Through a questionnaire survey, nursing record forms from various medical institutions were collected to identify existing issues and refine the content of the form. The Delphi method was employed to finalize the standardized surgical nursing record form.ResultsThe standardized surgical nursing record form comprises four core modules: preoperative, intraoperative, postoperative, and item inventory, along with clear instructions for completion. Conclusion The surgical nursing record form aligns with the regional characteristics of Shaanxi Province and will be gradually promoted for application.

参考文献/References:

［1］SETO R, ISHIKAWA M, OKUDARIA H,et al. Trial of converting nursing records into simplified and structured information utilizing ChatGPT-3.5［J］.Stud Health Technol Inform,2024,24(315):236-240.［2］TSURU S,TAMAMOTO T, FURUYA H, et al. Nursing record innovations aimed at harmonizing structured clinical knowledge among doctors and nurses［J］.Stud Health Technol Inform,2020,16:638-642.［3］AKHU-ZAHEYA L,AL-MAAITAH R,BANY HANI S.Quality of nursing documentation:paper-based health records versus electronic-based health records［J］.J Clin Nurs,2018,27(3-4):e578-e589.［4］LEE S,JEON MY,KIM EO.Impl-ementation of structured documentation and standard nursing statements:perceptions of nurses in acute care settings［J］.Comput Inform Nurs,2019,37(5):266-275.［5］倪爱玲,李倩,徐宇红.全结构化电子护理记录单的开发与临床应用评价［J］. 护理学杂志,2022,37(1):49-52.［6］朱丽,鲁楠,张爽.质量评价指标管理对提高骨科护理记录单质量的效果观察［J］. 中国病案,2023,24(11):17-19.［7］李俊杰,张琳娟,梅娜,等.基于RCA的手术纱布清点不良事件改进效果研究［J］.中国卫生质量管理,2024,31(7):67-71.［8］郭栋,付秀荣,李恒.手术物品清点环节护理中断事件的危险因素分析［J］.中华护理教育,2024,21(5):574-579.［9］蔡嫦姗,张烁.优化手术护理记录单提高护理文书书写质量探讨［J］.中国病案,2022,23(12):19-21.［10］SCOTT ES,MURPHY LS,WARSHAWSKY NE.Nursing administration research priorities:findings from a delphi study［J］.J Nurs Adm,2016,46(5):238-244.［11］陈伶俐.手术室护理记录信息化对护理单书写质量及护理质量的影响［J］.中国病案,2020,21(9):21-23,112.［12］HAN Y,ZHANG Y,VERMUND SH.Blockchain technology for electronic health records［J］.Int J Environ Res Public Health,2022,19(23):15577.［13］张晓然,孙齐,俞莎莎.系统化手术护理记录单在普外科胃癌手术中的应用效果［J］.中国病案,2021,22(6):8-9,74.［14］王海娟,刘丹.围术期电子护理记录单对护理记录书写质量的影响［J］.中国病案,2023,24(5):21-23.［15］刘伟,向承红,耿苗苗,等.品管圈下的信息化管理对策在电子手术护理记录单中的应用［J］.中国病案,2024,25(7):12-14.

相似文献/References:

[1]管晓明张春艳李建高勇戴璐.以绩效精细化管理提升手术室护理质量[J].中国卫生质量管理,2019,26(06):19.[doi:10.13912/j.cnki.chqm.2019.26.6.06]
[2]王震杨霞*刘英敏赖双王淑.手术室移动护理信息平台的开发与应用[J].中国卫生质量管理,2020,27(04):104.
　WANG Zhen,YANG Xia,LIU Yingmin,et al.Development and Application of Mobile Nursing Information Platform in Operating Room[J].Chinese Health Quality Management,2020,27(12):104.
[3]卞伟峰辛玲伏瑜高蓓蓓.构建手术室护理质量敏感指标体系[J].中国卫生质量管理,2020,27(05):59.
　BIAN Weifeng,XIN Ling,FU Yu,et al.Construction of Sensitive Index System of Nursing Quality in Operating Room[J].Chinese Health Quality Management,2020,27(12):59.
[4]田小荣田艳妮.手术室男护士职业认同与工作压力、生活质量的相关性研究[J].中国卫生质量管理,2021,28(03):51.[doi:10.13912/j.cnki.chqm.2021.28.3.16 ]
　TIAN Xiaorong,TIAN Yanni.The Relationship among Professional Identity, Work Stress and Life Quality of Male Nurses in Operating Room[J].Chinese Health Quality Management,2021,28(12):51.[doi:10.13912/j.cnki.chqm.2021.28.3.16 ]
[5]温贤秀刘婉琳谢彩霞宋瑰琦杨丽方茜龚仁蓉易凤琼.手术室护理质量控制指标构建与应用[J].中国卫生质量管理,2022,29(10):17.[doi:10.13912/j.cnki.chqm.2022.29.10.04 ]
　WEN Xianxiu,LIU Wanlin,XIE Caixia.Construction and Application of Nursing Quality Control Index in Operating Room[J].Chinese Health Quality Management,2022,29(12):17.[doi:10.13912/j.cnki.chqm.2022.29.10.04 ]
[6]贾晋莉杨娟何小东吴兰兰赵倩倩.手术室智慧管理平台构建与应用[J].中国卫生质量管理,2023,30(01):67.[doi:10.13912/j.cnki.chqm.2023.30.1.15 ]
　JIA Jinli,YANG Juan,HE Xiaodong.Construction and Application of Operating Room Intelligent Management Platform[J].Chinese Health Quality Management,2023,30(12):67.[doi:10.13912/j.cnki.chqm.2023.30.1.15 ]
[7]李俊杰张琳娟梅娜罗嘉婷.基于RCA的手术纱布清点不良事件改进效果研究[J].中国卫生质量管理,2024,31(07):67.[doi:10.13912/j.cnki.chqm.2024.31.7.15]
　LI Junjie,ZHANG Linjuan,MEI Na.The Improvement Effect of Surgical Gauze Counting Adverse Events Based on Root Cause Analysis[J].Chinese Health Quality Management,2024,31(12):67.[doi:10.13912/j.cnki.chqm.2024.31.7.15]
[8]金永春王杰徐云华.基于物联网技术的手术室医疗设备管理系统建设与应用[J].中国卫生质量管理,2025,32(02):19.[doi:10.13912/j.cnki.chqm.2025.32.2.05]
　JIN Yongchun,WANG Jie,XU Yunhua.Construction and Application of Operating Room Medical Equipment Management System Based on Internet of Things Technology[J].Chinese Health Quality Management,2025,32(12):19.[doi:10.13912/j.cnki.chqm.2025.32.2.05]
[9]刘佩玉李雪云朱迪安晓燕王清.58所医院手术室护理缺失现状及影响因素分析[J].中国卫生质量管理,2026,33(5):60.[doi:10.13912/j.cnki.chqm.2026.33.5.12]
　LIU Peiyu,LI Xueyun,ZHU Di.Analysis of the Current Status and Influencing Factors of Missed Nursing Care in Operating Rooms Across 58 Hospitals[J].Chinese Health Quality Management,2026,33(12):60.[doi:10.13912/j.cnki.chqm.2026.33.5.12]

更新日期/Last Update: 2025-12-15