摘要
目的:探讨护理记录中存在的问题及应对措施。方法:对存在问题进行客观分析,增强法律意识,明确护理记录书写的重要性。结果:护理记录中存在的问题依次为:①医护记录不一致;②记录简单不准确,重点不突出,内容缺乏连续性等;③护理记录前后矛盾。结论:护士在不断提高专业技术水平的同时,还应增强法律意识,提高综合素质。
Objective： To explore problems in the nursing records and its countermeasures.Methods： Analyze these problems;enhance the legal awareness;impress on nurses the importance of keeping accurate records.Results： The problems in the nursing records were as follows： inconsistent recording,inaccurate recording,discontinuity of the content,no important points.Conclusion： The nurse should improve their comprehensive quality when enhancing professional capability.
出处
《大理学院学报（综合版）》
CAS
2012年第3期67-69,共3页
Journal of Dali University
关键词
护理记录
问题
应对措施
nursing records
problems
countermeasures
