摘要
目的通过对住院病案护理文书的质量分析,加强护理人员法律意识,提高护理病历书写质量。方法随机抽取2010年860份护理文书,包括护理记录单、医嘱单、体温单,进行检查分析。结果存在护理缺陷350项次,其中护理记录单缺陷180项次,体温单缺陷90项次,医嘱单缺陷80项次。结论住院病案护理文书是病人接受治疗和护理的全过程的记载,是医疗纠纷重要的法律依据,要高度重视病历中护理文书书写质量,加强护理人员法律意识,防范医疗纠纷。
objective Through analysis on quality of nursing documents in our hospital,we need to strengthen legal consciousness of nurses and to improve writing quality of nursing records.Methods 860 copies of nursing document were selected randomly from medical records in 2010,including the nursing records,prescription sheets,as well as temperature forms,had examination analysis.Results There are 350 points of defects in all documents,in which 180 from the nursing records,90 from prescription sheets,and 80 from prescription sheets.Conclusion Nursing documents of hospitalization medical records are record during treatment and nursing,as well as legal basis for medical tangle.We need to pay attention to the writing quality of nursing document with strengthening legal consciousness of nurses and preventing medical tangle.
出处
《中国病案》
2012年第5期25-26,共2页
Chinese Medical Record
关键词
病案
护理文书
缺陷分析
对策
Medical record
Nursing document
Defect analysis
Countermeasures
