摘要
[目的]研究分析综合ICU危重病人护理记录单中存在的相关问题,找出解决对策,提高记录质量,以保证护理安全。[方法]随机抽查2003年～2004年我院综合ICU护理记录单200份,对护理记录中出现的相关问题及所涉及的护理人员进行分析。[结果]200份特护记录单中,出现的问题主要为6大类22方面。这些出现的问题与护理人员的工作年限、学历、班次等因素有关。[结论]综合ICU护理记录单的质量与护理人员的学历、班次等因素,通过对不同护理人员进行相关知识培训,制定相关标准,实施质量保证管理,才能最终实现护理文书持续质量改进,从而避免引起医疗事故和纠纷。
Objectives： To research and analyze the problems on integrated ICU nursing record and find countermeasures to increase nursing record writing quality and assure nursing safety. Methods： Random selected 200 integrated ICU nursing records in our hospital from 2003 to 2004, and to analyze the related problems in these records. Results： The problems can be divided into 22 aspects within 6 catalogues in these 200 nursing records. They are timeliness （8.8%）, veracity （20.6%）, facility （28.5%）, integrality （26.1%）, objcctivity （5.1%）, and criterion （10.9%）. These problems are related to work years, education background, and duty times. Conclusions： The quality of integrated ICU nursing records is related to education background and duty times and so on. In order to realize increasing the quality of description constantly and avoid medical accident and tangle, related training should be exercised on particular nurses, related standard should be established and administration on quality should be actualized.
出处
《中国医院》
2009年第5期60-62,共3页
Chinese Hospitals
