Objective  To design nursing record sheet for day surgery in the Department of Ophthalmology and evaluate its effect through clinical application. Methods  The nursing record sheet for day surgery in the Department of Ophthalmology was designed based on the theory of forms and record control, using the method of process analysis and process reengineering and taking into consideration the characteristics of nursing care during day surgery in the Department of Ophthalmology. The adverse event rate in nursing for ophthalmologic surgery and the satisfaction rate of operating room nurses were calculated before and after the application of this record sheet. Results  From July to October 2015, the Department of Ophthalmology was involved in 9 cases (7.96%) of adverse events resulting from drawbacks of the nursing record design or mistakes in recording. From November 2015 to February 2016, the Department of Ophthalmology was involved in only 1 case (1.28%) of advense event resulting from defect caused by nuring record sheet; the difference was significant (P < 0.05). From July to October 2015, the satisfaction rate of oph thalmologic nurses before using the nursing record sheet was 54.33%, which was significantly improved to 98.71% from November 2015 to February 2016 after the utilization of the nursing record sheet. Conclusion  The nursing record sheet for day surgery in the Department of Ophthalmology has been appropriately designed and is easy to use, which can improve the quality of surgery nursing as well as the satisfaction of operating room nurses.

Citation： XuChenghui, CaoQing, JingJie. The Design and Application of Nursing Record for Day Surgery in the Department of Ophthalmology. West China Medical Journal, 2016, 31(4): 611-614. doi: 10.7507/1002-0179.201600166 Copy