护理记录书写中的问题分析及对策

为适应新的《医疗事故处理条例》，减少病历缺陷引起的医患纠纷，对出院病历护理记录书写质量进行检查。发现存在医护间记录不符、护理记录自身矛盾、涂改、遗漏、随意记录、字迹潦草、记录不规范等缺陷。提出加强护理人员法律教育，提高自我保护意识；加强医护间沟通，保持医疗护理记录的一致性；成立科室三级护理记录质控网络，加强护理记录过程中的质量控制；加强护士专业技术、文字书写等能力的培养，提高护理记录书写水平。

Anlysis of Nursing record and Countermeasures

In order to adapt to the new Regulations on the Medical Accident Treatment and reduce medical dispute owing to the faults of the nursing records, we check the quality of discharged nursing case. To discover existing questions, such as the contradictions between doctors notes and nurses' ones, mending notes, recording notes at random, poor handwriting and so on. To educate nurses about the consciousness of law and self-protection. To increase the communication of doctors and nurses, keep the consistence between doctors' notes and nurses' ones as well. To establish the system of three-grade quality control of nursing records as to make sure the quality of nursing notes. To develop the ability of professional nursing skills and to improve the quality of the nursing notes.