摘要
目的 分析护理记录单书写中存在的问题 ,查找原因 ,规范护理记录单的书写。方法 对出院病历中的 784份护理记录单进行检查分析。结果 护理记录单书写中存在的主要缺陷依次为记录简单不准确 ;病情记录未突出重点 ;内容缺乏连续性 ;未使用医学术语 ;项目填写不全或有误 ;医护记录不一致。一般患者与危重患者护理记录单比较具有统计学意义 ( 2 =7.3 7,P <0 .0 1)。结论 护理管理者必须加大护理记录单的检查与管理力度 ,重视护理人员的法律知识和文化业务素质的培训 。
Objective To investigate the flaws in the writing of nursing records, find out the reasons and standardize the nursing records in writing. Method 784 nursing records from the discharged case history were checked and analyzed.Results The main flaws in the writing of nursing records were as follows: too simple or incorrect records, lack of key point on the records of state of disease, lack of continuity, not use of the medical terms, incomplete and improper items, inconsistency between nursing and medical records. There was significant difference between general patients and severe patients in the flaws of writing ( 2=7.37,P<0.01).Conclusion Nursing administrators should pay more attention to the management and inspection on nursing records, attaching importance to the training of knowledge in law and professional diathesis for nursing staff, so as to standardize the nursing records in writing.Author’s address:Nursing Department,the First Hospital of Huai’rou District, Beijing 101400, China
出处
《护理管理杂志》
2004年第5期50-51,共2页
Journal of Nursing Administration
关键词
护理记录
缺陷
分析
nursing record
flaw
analysis
