摘要
本文通过对我院2004年8月～2005年6月出院病案中1895份护理记录质量检查,发现护理记录中主要存在：护理专业知识使用不当、保护病人安全的措施缺乏、记录缺乏客观性、真实性及完整性、医护记录不一致、护理记录不能反映出专科疾病特点及护理行为、不能反映出整体护理内涵等问题,提出应加强护士法制观念、加强新上岗护士和少数民族护士专业知识和护理记录书写技能培训、注重医护互补、加强科室间的横向联系、设计有专科特色的护理记录评估表、落实护理记录质量检查等对策以提高护理记录的书写质量,避免医疗纠纷的发生。
Based on the quality inspection on 1895 nursing records of medical records for leaving hospital from August 2004 to June 2005, it has been found the fallowing problems mainly exist in nursing records： inappropriate use of nursing professional knowledge, lack of measures to protect the patients＇ safety, absence of objectivity, authenticity, and integrality in the records, disagreement between medical records and nursing records, inability to reflect the characteristics of professional disease and nursing behavior, as well as the significance of holistic nursing. It has been proposed to reinforce the conception of legal system among the nurses, improve the professional knowledge and training of writing skills in nursing records among the new nurses and ethnic nurses and pay greatcr attention to mutual contact between medical care and nursing, between different sections. It is also suggested to take such measures as designing the evaluation table for nursing records with professional characteristics, performing the quality inspection on nursing records to improve the writing quality in nursing records and prevent the medical tangle from happening.
出处
《中国病案》
2006年第1期17-18,共2页
Chinese Medical Record
关键词
护理记录
问题
对策
nursing record
problem： countermeasure
