Objective To study the role of head nurses in the management of practicing real-time recording of nursing.Methods The head nurse of our department conducted the management of the quality of the real-time recording of nursing by three stages.The satisfaction level, the time for senior nurses to write nursing records, the time for nurses to perform basic nursing, and the flaws in the recorded nursing documents found by hospital administrators were investigated and compared within the three atages.Results The satisfactian level after the quality control of nursing records at stage 3 was improved, the time for writing nursing records was shortened, the time for basic nursing was lengthened and the flaws at writing nursing records were lessened compared to pre-control.Conclusion The real-time nursing recording management by head nurses may shorten the time for writing nursing records, lengthen the time for basic nursing, improve the patient's satisfaction degree, reduce the flaws in nursing documents and enhance the quality of nursing documents.%目的 探讨护士长在实施实时护理记录中的管理作用.方法 2009年3月-2010年3月本科室护士长实施实时护理记录管理,分3个阶段对护理记录进行质控管理,比较3个阶段的病人满意度,平均每天护理记录书写时间、基础护理时间以及医院各层级人员对护理记录书写质量检查缺陷情况.结果 护士长实施实时护理记录质控管理后,第3阶段与第1阶段比较,提高了病人的满意度,缩短了每天护理记录书写时间,增加了基础护理时间,降低了护理记录书写缺陷.结论 护士长实施实时护理记录管理有利于缩短护理记录书写时间,把时间还给病人,增加了基础护理时间,提高了病人的满意度;同时也降低了护理记录书写缺陷,提高了护理记录书写质量.
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