中文摘要：

目的 简化一般患者护理记录的模式,减少书写量,节省书写时间.方法 选择参与书写护理记录的护士共150人分两个时间段进行问卷调查;运用分层、随机、单盲的方法将150名参与书写护理记录的内、外科护士分为实验组和对照组,选择纳入标准病例,在使用表格式护理记录单的基础上,对照组实施现行的书写要求,实验组实施简化的书写要求,对两组记录从书写时间和质量方面进行测评分析.结果 问卷调查结果显示：现行书写护理记录的满意度明显低于简化护理记录的满意度（P＜0.01）.实验结果显示：两组的第一次护理记录,一次的护理过程记录,出院护理记录所用的时间差异有统计学意义（P＜0.01）;两组护理记录中监测数据的准确性、完整性、及时性、中医辩证施护内容比较差异有统计学意义（P＜0.05）.结论 简化护理记录中与医师重复书写的内容,既遵行法律责任和保证护理安全的原则,又真正减少护士的书写量,缩短书写时间,提高工作效率和护理服务的满意度.

英文摘要：

Objective To investigate the general patient care record mode,in order to reduce the amount of writing and writing time.Methods 150 nurses were selected and investigated about their writing and nursing records to answer questionnaire in two periods.All nurses were divided into experimental group and control group by stratified,randomized,single-blind method.We chose them to be included in the standard case,on the basis of the control group,control group used the current writing requirements,experimental group used the simply writing requirement.Finally we evaluated the two groups by writing time and the quality of the two sets of records.Results The survey results showed the existing writing nursing records＇ satisfaction was significantly lower than the simplified care records＇ satisfaction （P〈0.01）.The experimental results showed the differences of the time that groups first nursing records,the first nursing process record and discharged nursing records cost were significant （P〈0.01） and the differences of accuracy,completeness,timeliness,Chinese medicine dialectical nursing between data in the two groups of nursing records were significant （P〈0.05）.Conclusions Compared with the control group,the experimental group simplifies the nursing records and physician repeated written content,can both comply with legal obligations and ensure the care and safety of principle,and really reduce the amount of nurses writing,shorten writing time,and improve working efficiency and satisfaction with nursing care.