摘要
为分析护理文书书写中存在的缺陷及干预策略,在贵州省六盘水市钟山区人民医院终末护理文书检查子系统中,调取2022年5月—2023年5月的终末护理文书,按照随机抽样法,在每个科室抽取100份,合计检查1300份文书,按照科室、问题类型及检查问题清单方式进行统计,分析文书检查情况及缺陷情况。结果显示,在1300份终末护理文书中,合格护理文书有1253份,不合格护理文书有47份,合格率为96.38%。根据缺陷内容,不合格护理文书可分为3种类型,即体温单、医嘱单以及护理记录,其中,体温单占比为22.63%、医嘱单占比为15.54%、护理记录占比为61.83%。研究发现,采取强化护理人员护理文书书写规范化培训等相关干预措施,能够增强护理人员的护理文书书写规范化意识,从而降低护理文书的缺陷率,提高护理文书书写质量,避免发生医疗纠纷。
Analyze the deficiencies and intervention strategies in nursing document writing.In the terminal nursing document inspection subsystem of People's Hospital of Zhongshan Country in Liupanshui City,Guizhou Province,the terminal nursing documents from May 2022 to May 2023 were retrieved.According to the random sampling method,100 documents were selected from each department,and a total of 1300 documents were inspected.Statistics were made according to the department,the type of problems and the list of inspection problems,and the document inspection and defects were analyzed.The results showed that out of 1300 end-of-life nursing documents,there were 1253 qualified nursing documents and 47 unqualified nursing documents,with a qualification rate of 96.38%.According to the defect content,unqualified nursing documents can be divided into three types,namely temperature sheets,medical orders,and nursing records.Among them,temperature sheets account for 22.63%,medical orders account for 15.54%,and nursing records account for 61.83%.Research has found that adopting intervention measures such as strengthening standardized training for nursing document writing among nursing staffcan enhance their awareness of standardized nursing document writing,thereby reducing the defect rate of nursing documents,improving the quality of nursing document writing,and avoiding medical disputes.
作者
龚代英
Gong Daiying(People's Hospital of Zhongshan Country,Liupanshui,Guizhou 553000)
出处
《科技与健康》
2023年第10期114-117,共4页
Technology and Health
关键词
护理文书
缺陷
干预对策
nursing documents
defects
intervention strategies
