摘要
[目的]提高护理文件的书写质量,防范医疗纠纷发生。[方法]以方便抽样方式抽查我院外科110份护理文件,对存在的问题进行总结分析。[结果]护理记录缺陷可分为6类:缺项及漏项;病情记录不全面,缺乏联贯性;书写不规范;主观判断,记录欠真实;未及时修改护嘱;医护记录不一致。[结论]提高护理人员的法律意识和责任意识,规范和培训护理文件的书写,开展多层次的业务培训和学习,建立护理文件质量控制网络,对提高护理文件的书写质量,防范医疗纠纷发生非常必要。
Objective： To improve the quality of nursing files writing and to prevent the occurrence of medical disputes. Methods： A total of 110 pieces of surgical nursing files in our hospital were checked randomly by convenient sampling. And existed problems were summed up and analyzed. Results： Nursing record defects can be classified into six categories including incomplete items and omission items, un - allround pathography and lack of consistency, nonstandard writing, subjective judgment and unreal record, not modifying nursing order in time, and disparity records between doctors and nurses. Conclusion： It is necessary to improve legal and responsible consciousness of nursing staffs, to standardize nursing files writing, to carry out multi - level professional training and learning and to construct nursing files quality control network for both enhancing the quality of nursing files writing and the prevention of medical disputes.
关键词
护理文件
法律意识
质量控
制
网络
nursing files
legal consciousness
quality control
network
