急诊入院病人院内护理交接记录单的设计与使用

摘要

Objective:To standardize the handover procedure in emergency admission patients, assure the safe-ty and orderliness of patient handover, reduce the potential medical disputes and improve the satisfaction of pa-tients. Method:According to the routine treatment of patients in emergency resuscitation room and the key points of handover, a handover record sheet was designed and applied in clinics,which abided by the rules including clarif-ying the responsibility, simplicity in practice, benefiting patients and convenience for handover. Results:No medi-cal dispute or complaint was reported after the application since January,2014. The time of handover was shortened and the call inquiries because of unclear handover reduced. The treatment of nurses in emergency rescuing zone was more standard and the satisfaction of patients and their families was improved. Conclusion:The newly de-signed handover record sheet accurately reflects all kinds of patients' information, facilitates the handover, can re-duce the unsafe factor, improves the work efficiency, standardizes nursing behavior in emergency rescuing, and im-proves the satisfaction of medical service.%目的：规范急诊入院患者的交接，保证患者交接的安全、有序，降低潜在的医患纠纷，提高患者的满意度。方法遵循明确责任、使用简便、有利病人、方便交接的原则，根据急诊抢救室病人处置常规及急诊入院病人交接关注要点等，自行设计急诊入院病人院内护理交接记录单并应用于临床。结果从2014年1月使用以来，无1例相关纠纷与投诉发生，病人交接时间缩短，因交接不清电话询问的次数明显减少，急诊抢救区护士在病人送入病区前的处置更加规范，患者及家属满意率上升。结论急诊入院病人院内护理交接记录单准确反映了病人的各类信息，便于交接，可减少不安全因素，提高工作效率，同时可规范急诊抢救护理行为，提高医疗服务满意度。