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中国科技核心期刊（中国科技论文统计源期刊）
中国科学引文数据库（CSCD）核心库期刊
《中文核心期刊要目总览》核心期刊

中国护理管理 ›› 2026, Vol. 26 ›› Issue (5): 766-771.doi: 10.3969/j.issn.1672-1756.2026.05.025

• 专科管理 • 上一篇    下一篇

连续性肾脏替代治疗结构化护理记录单的设计与应用

曹培叶 左力 陈娜 吴璇 王磊   

  1. 北京大学人民医院肾内科，100044 北京市
  • 出版日期:2026-05-15 发布日期:2026-05-15
  • 通讯作者: 左力，博士，主任医师，科室主任，E-mail:zuoli@bjmu.edu.cn
  • 作者简介:曹培叶，硕士，主管护师，护士长
  • 基金资助:
    北京大学人民医院研究与发展基金（RDN2022-21）

Design and application of a structured nursing documentation form for Continuous Renal Replacement Therapy

CAO Peiye, ZUO Li, CHEN Na, WU Xuan, WANG Lei   

  1. Department of Nephrology, Peking University People’s Hospital, Beijing, 100044, China
  • Online:2026-05-15 Published:2026-05-15
  • Contact: E-mail:zuoli@bjmu.edu.cn

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摘要： 目的：设计连续性肾脏替代治疗（Continuous Renal Replacement Therapy，CRRT）结构化护理记录单并分析其应用效果，为推动CRRT患者护理质量的进一步提升提供参考。方法：基于临床需求设计CRRT结构化护理记录单初稿，通过专家会议讨论修改并形成终稿。将结构化护理记录单嵌入CRRT信息化平台，应用于临床，以北京市某三级甲等医院2024年7月—12月的226例患者为应用前组，2025年1月—6月的327例患者为应用后组。对比应用前后的CRRT护理记录单书写时长、护理记录规范率、非计划性下机发生率、超滤剂量达成率，并评估应用后医护人员使用满意度。结果：记录单包含患者基本信息、治疗相关临床资料、治疗前评估、治疗监测、治疗后评估、治疗总结6个模块。应用后，CRRT护理记录单书写平均时长由22（18，25）min，降至13（11，15）min（P<0.001），护理记录规范率由96.9%升至100.0%（P=0.002），非计划性下机发生率由17.7%下降至9.8%（P=0.009），超滤剂量达成率由85.4%升至91.1%（P=0.001），医护人员使用满意度评分为（71.57± 4.70）分。结论：基于信息化平台的CRRT结构化护理记录单的应用提升了护理记录工作效率和记录质量，进一步改善了CRRT专科护理质量和治疗效果。

关键词: 连续性肾脏替代治疗；结构化护理记录单；信息化

Abstract: Objective: To design a structured nursing documentation form for Continuous Renal Replacement Therapy (CRRT), and analyze its application effects, thereby providing a reference for further improving the nursing quality of patients undergoing CRRT. Method: Based on the clinical requirements of CRRT, a preliminary draft of the structured nursing record sheet for CRRT was designed. The draft was discussed and revised through expert meetings to form the final version. The structured nursing record sheet was embedded into the CRRT information platform and applied in clinical practice. A total of 226 patients of a tertiary grade A hospital in Beijing from July to December 2024 served as pre-application group, and 327 patients from January to June 2025 as the post-application group. Comparisons were made between pre- and post-implementation regarding the time required for completing CRRT nursing documentation, the compliance rate with nursing documentation standards, the incidence of unplanned discontinuation, and the achievement rate of ultrafiltration dose. Additionally, healthcare providers' satisfaction with the form was evaluated after the implementation. Results: The structured CRRT nursing documentation form included six core modules: patient demographic information; treatment-related clinical data; pre-treatment assessment; treatment monitoring; post-treatment evaluation, and treatment summary. After the implementation, the average time to complete CRRT nursing documentation form decreased from 22 (18, 25) minutes to 13 (11, 15) minutes (P<0.001). The nursing documentation compliance rate increased from 96.9% to 100.0% (P=0.002). The incidence of unplanned discontinuation decreased from 17.7% to 9.8% (P=0.009), and the achievement rate of ultrafiltration dose improved from 85.4% to 91.1% (P=0.001). The overall user satisfaction score among healthcare providers was 71.57±4.70. Conclusion: The implementation of the structured CRRT nursing documentation form based on the information platform has enhanced the efficiency and quality of nursing documentation, and further improved the quality of specialized CRRT nursing care, as well as the treatment effects.

Key words: Continuous Renal Replacement Therapy; structured nursing documentation form; informatization

中图分类号:  R47；R197
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