摘要
目的提高手术病人护理文件的书写质量。方法对我院6 298例手术病人的护理文件进行认真检查,对存在的问题进行分析并提出相应对策。结果出现的护理记录缺陷可分为3类:缺项及漏项;记录不一致;对病人病情描述不全面。结论加强法律知识的学习,强化护士自我保护意识;狠抓护理质量,增强护理质量意识;针对不同护士进行有针对性的护理文件书写培训;提高现有人力资源的利用率,对提高手术病人护理文件的书写质量非常必要。
Objective To improve the quality of nursing records of operation patients. Methods 6 298 cases of nursing records in operation room were retrospectively checked. Then the problems were analyzed and some countermeasures were proposed, Result The main defects in nursing records involved in three aspects, including omission, inconsistency and incompleteness. Conclusion In order to improve the quality of nursing records in operation room, it is necessary, to strengthen the study of legal knowledge,enhance nurses＇ awareness of self- protection,enforce quality control and quality consciousness, provide training for the nurses in writing nursing records ,and improve the efficiency of utility of nursing human resource.
出处
《护理管理杂志》
2006年第8期20-21,共2页
Journal of Nursing Administration
关键词
手术
护理文件
缺陷
对策
operation
nursing records
defect
countermeasures
