摘要
目的应用目标管理原则设计牙周护理记录单,以期达到提升护理人员记录水平,促进护理记录质量提高的目的。方法从某院HIS系统中随机选取2018年7月1日-2019年8月15日门诊收治的47例慢性牙周炎患者的护理记录单为对照组,随机选取2021年9月1日-2021年10月23日门诊收治的43例慢性牙周炎患者的护理记录单为观察组。对照组采用医院常规的牙周护理记录单,观察组采用目标管理下牙周护理记录单记录。比较2组护理记录书写质量评分,并对2组护理人员记录书写相关能力进行考核。结果观察组护理记录书写质量(95.63±2.40)分显著高于对照组(93.58±2.44)分,差异有统计学意义,P<0.05,观察组书写能力总分(92.34±2.34)分高于对照组(90.71±2.41)分,差异有统计学意义,P<0.05。结论基于目标管理下牙周护理记录单在慢性牙周炎患者中应用可提升护理人员记录水平,促进护理记录单记录质量提高,值得推广应用。
Objectives To design the periodontal nursing record sheet by applying the principle of management by objectives,in order to improve the level of nursing staff's record and promote the quality of nursing record.Methods The nursing records of 47 patients with chronic periodontitis admitted to the outpatient department from July 1st,2018 to August 15th,2019 were randomly selected from HIS system of a hospital as the control group,and the nursing records of 43 patients with chronic periodontitis admitted to the outpatient department from September 1st,2021 to October 23th,2021 were randomly selected as the observation group.The control group was treated with the routine periodontal nursing record sheet,and the observation group was treated with the target management periodontal nursing record sheet.The score of nursing record writing quality was compared between the two groups,and the related ability of nursing staff in the two groups was evaluated.Results The writing quality of nursing records in the observation group(95.63±2.40)was significantly higher than that in the control group(93.58±2.44),and the difference was statistically significant(P<0.05).The total score of writing ability in the observation group(92.34±2.34)was higher than that in the control group(90.71±2.41).The difference was statistically significant,P<0.05.Conclusions The application of goal-based management of lower periodontal nursing record sheet in patients with chronic periodontitis could improve the nursing staff's record level and promote the quality of nursing record sheet,which was worthy of popularization and application.
作者
栗楠
张朝霞
Li Nan;Zhang Zhaoxia(Beijing Chaoyang Hospital Affiliated to Capital Medical University,Beijing 100020,China)
出处
《中国病案》
2023年第12期24-26,共3页
Chinese Medical Record
关键词
牙周护理记录单
慢性牙周炎
目标管理
Periodontal nursing record sheet
Chronic periodontitis
Management by objectives
