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标准化护理语言继续教育项目对伊巴丹大学学院医院护士护理记录的影响。

Effect of standardized nursing language continuing education programme on nurses' documentation of care at University College Hospital, Ibadan.

作者信息

Adubi Iyanuoluwa O, Olaogun Adenike A, Adejumo Prisca O

机构信息

Clinical Nursing Department University College Hospital Ibadan Nigeria.

Department of Nursing Science Obafemi Awolowo University Ile-Ife Nigeria.

出版信息

Nurs Open. 2017 Nov 27;5(1):37-44. doi: 10.1002/nop2.108. eCollection 2018 Jan.

DOI:10.1002/nop2.108
PMID:29344393
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC5762716/
Abstract

AIM

The study assessed the documentation of nursing care before, during and after the Standardized Nursing Language Continuing Education Programme (SNLCEP). It evaluates the differences in documentation of nursing care in different nursing specialty areas and assessed the influence of work experience on the quality of documentation of nursing care with a view to provide information on documentation of nursing care. The instrument used was an adapted scoring guide for nursing diagnosis, nursing intervention and nursing outcome (Q-DIO).

DESIGN

Retrospective record reviews design was used.

METHODS

A total of 270 nursing process booklets formed the sample size. From each ward, 90 booklets were selected in this order: 30 booklets before the SNLCEP, 30 booklets during SNLCEP and 30 booklets after SNLCEP.

RESULTS

Overall, the study concluded that the SNLCEP had a significant effect on the quality of documentation of nursing care using Standardized Nursing Languages.

摘要

目的

本研究评估了标准化护理语言继续教育项目（SNLCEP）实施前、实施期间及实施后的护理记录情况。它评估了不同护理专业领域护理记录的差异，并评估了工作经验对护理记录质量的影响，以期提供有关护理记录的信息。所使用的工具是一份经过改编的护理诊断、护理干预及护理结果评分指南（Q-DIO）。

设计

采用回顾性记录审查设计。

方法

总共270本护理流程手册构成样本量。从每个病房按此顺序选取90本手册：SNLCEP实施前30本手册、SNLCEP实施期间30本手册以及SNLCEP实施后30本手册。

结果

总体而言，该研究得出结论，SNLCEP对使用标准化护理语言的护理记录质量有显著影响。

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