成人首次护理记录单书写质量缺陷分析与管理对策

目的：分析入院已归档成人患者首次护理记录单书写质量缺陷，探究减少首次护理记录单错误，提高其质量的方法。方法收集已归档成人患者的首次护理记录单3482份，分析发现其中存在的质量缺陷，并进行归纳总结，探究解决方案。结果在检查的3482份病历存在质量缺陷的有98份，占总数的2.8%，总共出现111次质量缺陷。其中在首次护理记录单中只出现一次质量缺陷有88份；出现两次质量缺陷有8份；出现2份有三次或者三次以上质量缺陷。结论首次护理记录单存在比较严重的书写质量问题，应该增强护理人员的法律意识，加强医护之间、护患之间的沟通，加强专业知识的学习，重视病例标准化问题，使质控团队更加健全，更有利于在护理各项活动中，使护患间的合法权益得到更好的保障。

Analysis and Management Countermeasures of the Quality Defects of the First Nursing Records

Objective To explore the method of improving the quality of the first nursing records of the patients admitted to the hospital for the first time in order to reduce the error of the first nursing record.Methods From June 2014 to 2015 January,ad-mission archived adult patients with the first nursing record single 3482 copies,the analysis found that which of the defects and summarized,explore solutions.Results In the examination of 3482 medical records in the presence of quality defects of 98 copies, accounting for 2.8%of the total,a total of 111 times the quality of defects.Only once quality defects have 88;Two quality defects 8;Appear three times or more than three times the quality defects of 2.Conclusion The first nursing record single exist more serious problems,the nursing staff should be enhanced their awareness of the law and strengthen between doctors and nurses,nursing com-munication between patient and strengthen the study of professional knowledge,strengthen consciousness of medical record writing standard,perfect quality control team,and in nursing,nursing between the patients and the legitimate rights and interests can be guaranteed.