一份完整的護理記錄可作為溝通，調查研究、稽核、教育及法律證明之文件。一 般外科住院病患中約 90% 身上有傷口，因此護理時需著重連續性的觀察及照護， 而傷囗有 無感染及癒合情形皆會影響患者的病情進展及住院日數，所以護理記錄完整性及一致性是關 鍵所在。本專案自 86 年 3 月 12 日至 6 月 25 日，以經過良好效度及信度測試之傷囗護 理記錄調查表，測驗護理人員對傷口護理的認知；以傷口護理記錄評值表，評值記錄的完整 性。 結果發現：人員認知度達 92.6%，但護理記錄完整性僅 31%， 而每班每位人員需費時 43.1 分鐘書寫十本記錄。 因此本專案依據北美護理診斷組織完整性受損的概念制定一般外 科傷囗護理記錄標準格式，提升護理記錄的完整性。以立意取樣針對台灣北部某醫學中心某 一般外科病房之護理人員進行評值分析， 及收集相關資料以 2-sample test 及 paired t-test 進行分析， 發現完整性由原來 31% 提升至 87.7%， 而所花費之時間出原來每本 4.31 分鐘減少至 3.1 分鐘，均在統計上有明顯之差異。由此評值結果得知所設計之一般外 科傷口護理記錄標準可達到增加記錄完整性以及節省時間之效。

　　　　　A complete care record can be used to 'be a document for communication, studying, researching, evaluation, and the evidence of law. Ninety percent of the general surgery patients admitted in hospital having wounds. So it is necessary for staff to emphasis on continuing observation and care. Both of the wound infection and healing process are important factors which influence the length of stay in the hospital. Therefore the completeness and consistence of a care record are the key points. This project started from 3-12,1997 to 6-25,1997. The authors used "wound care checklist" which passed the great utility and reliability test to examine the nurses' the cognitive about wound nursing. The authors also use "wound care checklist" to evaluate the completeness of evaluation record. The results were that the degree of nursing cognitive reaches 92.6@ but the completeness of nursing record only reaches 31%. Due to above survey, the authors designed the standard form of general surgery wound care record according to the concept of NADNA 's damage of tissue completeness to advance the completeness of care record. It processed evaluation and data collected by using purpose sample to nurses in some surgery ward of medicine center in north Taiwan. In the process of analysis, two-sample t-test and paired t-test were used to alanyze the completeness, and found that the completed rate increased from 31% to 87.7 % and the record time reduced from 4.3 minutes to 3.1 minutes. These are significant difference in statistics. As the result, we find that the standard of general surgery wound nursing record will increase the completeness of record and saving time.