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