[威尼托地区护理记录的使用情况]

[The use of nursing records in the Veneto region].

作者信息

Degan M

出版信息

Riv Inferm. 1995 Oct-Dec;14(4):167-72.

Abstract

Use and quality of nursing records used in the Regione Veneto hospitals was evaluated. An open ended questionnaire was sent to the nurses managers of each hospital. The questionnaire asked some general information on the hospital (number of beds, number and qualification of nursing personnel) and nurses managers were asked to send a blank copy of the nursing records in use. 21 nurses managers answered, overall responsible for 28 hospitals. Nurses records are used in 78 wards over 412 (19.1%). The wards are different for specialty and characteristics. Apparently, the only factor associated with the implementation of nursing records is the number of beds, with a wider implementation of nursing records in smaller hospitals. No association was found with the level of qualification of the nursing personnel. 11 nursing records were received. The items to be compulsorily monitored were mostly physical needs (i.e. elimination, hygiene, nutrition, mobilization), with the exception of the two records used in the psychiatric wards, where data on the behaviour and reaction of the patient was available.

摘要

对威尼托大区医院使用的护理记录的使用情况和质量进行了评估。向每家医院的护士管理人员发送了一份开放式问卷。问卷询问了有关医院的一些一般信息（病床数量、护理人员数量和资质），并要求护士管理人员发送一份正在使用的护理记录的空白副本。21名护士管理人员回复，总共负责28家医院。在412个病房中有78个病房（19.1%）使用护理记录。这些病房的专科和特点各不相同。显然，与护理记录实施相关的唯一因素是病床数量，护理记录在较小的医院中实施得更为广泛。未发现与护理人员资质水平有关联。收到了11份护理记录。除精神科病房使用的两份记录外，强制监测的项目大多是身体需求（即排泄、卫生、营养、活动），精神科病房的记录中有患者行为和反应的数据。