摘要
目的为提高精神科的护理记录质量,使之适应新的《医疗事故处理条例》实施的要求,减少护理记录缺陷引起的纠纷,加强护理人员自我保护的意识。方法通过对本院2003年5月～2004年4月出院患者的护理记录书写质量的评审。结果分析护理记录存在的缺陷有5类:1)护理记录与医疗记录不一致;2)未能科学客观地记录病情或护理记录前后不一致;3)护理记录不准确、不及时、不完整、表达不清;4)记录欠连续性和护理效果评价不及时,存在可能引起争议的记录;5)忽视了患者及家属的知情权。结论针对存在问题,提出相应的干预对策:1)护理记录内容要准确,与医疗病历记载及客观实际一致;2)认真观察,准确记录。3)加强对护士的业务培训,提高书写质量;4)强化护理行为中的法律意识,加强自我保护;5)尊重患者及家属的知情同意权;6)实施全程、全员参与质控。
To improve the quality of the psychiatric nursing records, make it adapt to the requirement of Treatment Rules of Medical Accidents, decrease the dispute caused by the flaws of nursing records and strengthen the self-protection of nurses. Methods In this article, we analyzed all the nursing records of the patients from May 2003 to April 2004. Results We point out 5 aspects of flaws, including： 1） nursing records not matching the doctor＇s; 2） nursing records not matching the practical measures; 3） nursing records not accuracy, not timely, not integrated and having unclear express; 4） nursing records not continuously and the effect-assessing not on time and even having the disputable records; 5）ignoring the consent right of the patients and their dependents. Then, We posed the corresponding countermeasures： Serious observing, timely and accurate recording, and improving the quality of the records; enhancing lawful education among nurses and promoting the self-protection, the consent rights being respected, attaching importance of quality control to all nurses and all courses. Conclusions Only having done them, we can improve the quality of nursing records and decrease the radio of the dispute in the nursing practice.
出处
《现代护理》
2005年第15期1258-1259,共2页
Modern Nursing
关键词
精神科
护理记录
隐患
干预
Department of psychiatry
Nursing records
Potential dispute
Intervention
