摘要
目的分析360份护理记录中存在问题,探讨在当前医患环境下如何提高护理文书质量,消除安全隐患。方法随机抽取2008年2月-2010年5月本院内科出院患者360份护理记录,对其存在问题进行分析,并提出对策。结果护理记录中存在问题包括涂改与缺项60份(16.7),护理记录不全面51份(14.2),医护记录不吻合36份(10.0),护理记录与医嘱不符33份(9.2),护理记录之间不衔接27份(7.5),护理记录前后矛盾15份(4.2)。结论加强对护士的法律意识及护理记录书写能力培训教育,制订并执行护理文件的综合评价标准细则,加强护士护理记录质量环节质控等,可提高护士护理记录的书写质量。
Objective To study the method for improving the quality of nursing documentation in current doctor-patient relationship and to eliminate hidden safety dangers.Methods 360 nursing records from Feb.2008 to May 2010 were selected at random.The issues in them analyzed and the coping strategies were proposed.Results Problems in nursing records included alteration of nursing records,missing of items in 60（16.7%）,incomplete recording in 51（14.2%）,differences from medical records in 36（10.0%）,difference from the doctor＇s orders in 33（9.2%）,inconsistency in recording in 27（7.5%）,contradiction against each other in 15（4.2%）.Conclusion The strategies of strengthening the law awareness education for nurses,regulating standards for a comprehensive evaluation of nursing documentation and enhancing quality control on nursing documentation and improving the nurse-patient communication are pertinent for the improvement of nursing documentation.
出处
《现代临床护理》
2011年第3期60-61,52,共3页
Modern Clinical Nursing
关键词
护理记录
护理病历
护理管理
nursing documentation
nursing records
nursing management
