摘要
目的探讨危重患者护理记录中存在的缺陷,并针对缺陷实施对策,提高护理记录的书写质量。方法抽查2017年3—4月ICU危重患者护理记录150份,按照护理记录书写要求,分别对记录的客观性、及时性、准确性、真实性和完整性缺陷进行分析,提出对策。结果2017年5—7月通过对策实施,科室危重患者护理记录书写合格率在7月底的检查中由整改前的88%提高到93%。结论护理人员要不断规范自己的行为,才能在"举证责任倒置"的医疗环境下保护自身及同行,提高自身对患者的护理质量。
Objective To investigate the defects in the nursing records of critical patients and to improve the writing quality of nursing records.Methods From March to April 2017,150 ICU critical care records were taken,according to nursing record writing requirement,objectivity,timeliness,accuracy,authenticity and integrity of the records were analyzed respectively,propose countermeasures.Results From May to July 2017 by implementation of countermeasures,nursing records of critically ill patients with qualified rate at the end of July before the 88% rectification inspection by up to 93%.Conclusion Nursing staff should constantly regulate their behavior in order to protect themselves and their counterparts in the medical environment of ＂burden of proof inversion＂,and improve their quality of care for patients.
出处
《中国继续医学教育》
2017年第20期227-229,共3页
China Continuing Medical Education
关键词
ICU
护理记录
缺陷
对策
ICU
nursing records
defect
countermeasures
