目的:了解综合性医院护士分级护理医嘱准确性及影响因素.方法:2015年1月~2016年12月随机抽取本地区3家综合性医院内科、外科2个系统16个科室858例住院患者作为调查对象,自行编制"临床分级护理适用性调查表",针对不同护理级别的患者选用相应的调查表进行护理实施内容及护士实施内容所用时间来评定.结果:特级护理、一级护理、二级护理、三级护理实际评定与分级护理医嘱符合率分别为89.66%,85.41%,74.11%,90.38%,总体符合率82.52%;综合性医院外科395例患者,分级护理医嘱与实际护理评定符合率84.55%,内科系统463例患者,符合率81.21%.结论:分级护理医嘱与实际护理评定存在差异,应该及时修订护理等级,加强医师对护理等级的重视,准确开具分级护理医嘱,提高护理活动的严谨性、可操作性.%Objective:To understand the medical advice accuracy for graded nursing of nurses in general hospitals and its influential factors.Methods:Randomly sampled 858 inpatients from 16 departments of medicine and surgical systems of 3 general hospitals in our area from January 2015 to December 2016 as the investigation objects, "investigation from on applicability of clinical graded nursing" was prepared, and the corresponding investigation form was selected for patients of different nursing grades to evaluate the nursing implementation contents and time spent by the nurses in implementation.Results:The conformance rates of actual rating to graded nursing medical advice of special nursing, Grade 1 nursing, Grade 2 nursing and Grade 3 nursing were respectively 89.66%,85.41%,74.11% and 90.38%, with overall conformance rate 82.52%;in the 395 patients from surgery department of the general hospitals, the conformance rate of graded nursing medical advice to actual nursing rating was 84.55%;in the 463 patients of the internal medicine system, the conformance rate was 81.21%.Conclusion:There was a difference between the graded nursing medical advance and the actual nursing rating, it was required to modify the nursing grade, strengthen the emphasis of physicians on nursing grade, accurately issue medical advice of graded nursing and improve the prudence and operability of the nursing activity.
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