Improvement and application of nursing assessment record sheet in hernia day surgery ward

doi:10.3877/cma.j.issn.1674-392X.2023.05.035

Abstract

Abstract:

Objective

To investigate the effect of improved nursing assessment record sheet in hernia day surgery ward.

Methods

According to the actual needs of clinical day surgery nursing work in Beijing Chao Yang Hospital, the nursing documents were modified and integrated, and the relevant data such as evaluation time, recording time and writing quality of nursing documents before and after the improvement were analyzed.

Results

The preoperative evaluation time after the improvement was (4.64±1.71) minutes, which was significantly lower than that before the improvement (5.71±2.02 minutes). After the improvement, the total recording time was (4.12±0.72) minutes, which was significantly lower than that before the improvement (6.41±1.87 minutes). Nursing document writing quality score was higher after improvement (99.88±0.48) than that before improvement (98.84±1.67). The score of nurses’ evaluation for the nursing assessment record sheet after the improvement (99.14±1.07) was significantly higher than that before the improvement (72.57±3.60), and the difference was statistically significant.

Conclusion

The improved day ward nursing assessment sheet can effectively improve the writing efficiency and quality of nursing documents, reflect the content of nursing work more completely and comprehensively, standardize and guide clinical nursing work, and improve nurses' satisfaction.

Key words: Day surgery, Hernia surgery, Nursing assessment

Lei Shuang, Hongjin Fan, Zhaoyuan You. Improvement and application of nursing assessment record sheet in hernia day surgery ward[J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2023, 17(05): 662-666.

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References 24

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组别	例数	术前评估时长	总记录时长	术前记录时长	术后记录时长
改良前组	50	5.71±2.02	6.41±1.87	3.70±0.75	2.71±0.33
改良后组	50	4.64±1.71	4.12±0.72	2.23±0.38	1.93±0.42
t		1.907	5.86	5.55	4.60
P		0.073	<0.001	<0.001	<0.001

组别	例数	术前评估时长	总记录时长	术前记录时长	术后记录时长
改良前组	50	5.71±2.02	6.41±1.87	3.70±0.75	2.71±0.33
改良后组	50	4.64±1.71	4.12±0.72	2.23±0.38	1.93±0.42
t		1.907	5.86	5.55	4.60
P		0.073	<0.001	<0.001	<0.001

组别	例数	工作效率与成本	文档结构合理性	书写便利性	内容专业性	总得分
改良前组	50	15.00±0.82	11.29±1.70	12.29±1.25	34.00±1.15	72.57±3.60
改良后组	50	19.71±0.49	20.00±0.00	20.00±0.00	39.43±0.79	99.14±1.07
t		13.11	13.53	16.28	26.87	23.50
P		<0.001	<0.001	<0.001	<0.001	<0.001

组别	例数	工作效率与成本	文档结构合理性	书写便利性	内容专业性	总得分
改良前组	50	15.00±0.82	11.29±1.70	12.29±1.25	34.00±1.15	72.57±3.60
改良后组	50	19.71±0.49	20.00±0.00	20.00±0.00	39.43±0.79	99.14±1.07
t		13.11	13.53	16.28	26.87	23.50
P		<0.001	<0.001	<0.001	<0.001	<0.001

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