摘要
目的:强化责任护士实时动态书写护理记录的重要性,增强护士在医疗纠纷中自我保护法律意识。方法:通过落实三级质控网,实施自下而上的三级质控:责任护士→护理组长→护士长,选择交接班、患者病情变化、转科等不同的时机床边质控责任护士动态书写的护理记录,培养责任护士养成床边实时动态书写护理记录的习惯,能客观、真实、准确、及时、完整反应患者的病情。结果:护理记录能更客观、真实、准确、及时、完整反应患者的病情变化,为防范医疗纠纷提供有效的法律依据。结论:实时动态护理记录扭转了举证乏力的困局,有力保障了医护人员的合法权益,可有效防范医疗纠纷的发生。
Objective：To strengthen the ~esponsibility of nurses the importance of real -time dynamic nursing record v.＇rlting, and enhance ~elf- protection awareness of the law of nurses in medical disputes. Methods ： Through the implementation of three level quality control network, the implementation of bottom -up three level quality control：responsibility nurse-＊nursing team leader--＊the head nurse, selection of patients with shift,change,mmsfer, different timing bedside nurse8 dynamic quality control the writing of nursing records, get into bed and real - time dynamic nursing record writing habits, nurse, can objectively true accurate, timely and completely response of the patient. Results：The nursing records can be more objective, true, accurate, complete, timely response to the patient＇s condition changes,provides the legal basis for the prevention of medical disputes. Conclusion ：Nursing records of real - time dynamic torsional fatigue problem,feguard the legitimate fights and interests of the staff, can effectively prevent the occurrence of medical disputes.
出处
《护理实践与研究》
2013年第12期78-79,共2页
Nursing Practice and Research
关键词
护理记录
实时动态
医疗纠纷
Nursing record
Real - time dynamic
Medical dispute
