600份护理文件书写质量分析及干预对策

目的 探讨600份护理文件书写质量分析及干预对策.方法 收集2016年1月-2018年1月医院住院的患者护理文件600份,对文件中的护理记录进行回顾性分析,总结护理文书书写中存在的缺陷并提出干预对策.结果 600份护理文件中,有229份存在不同方面的书写问题,其中体温单漏绘占21.83％,医嘱单漏项占13.10％,护理...

Analysis of writing quality of 600 nursing documents and intervention countermeasures

Objective To analyze the writing quality of 600 nursing documents and explore the intervention countermeasures. Methods A total of 600 medical records of patients in a hospital were collected from January 2016 to January 2018. The nursing records were analyzed retrospectively, and the defects in the writing were summarized and the intervention countermeasures were put forward. Results Among the 600 medical records, 229 had different writing problems, including 21.83% of temperature list problems, 13.10% of doctor's order list problems, 19.65% of nursing record list problems, 8.73% of ECG and blood pressure monitoring list problems, 13.10% of inpatient nursing evaluation list problems, 8.73% of inpatient health education evaluation problems, 6.99% of nursing handover list problems in surgical patients, and 7.86% of nursing handover record list problems. Among 229 medical records with writing problems, 25.33% of them had inaccurate language expression, 21.83% had inaccurate records, and 17.47% had altered records. Conclusion There are many defects in the writing of nursing documents in the hospital. We should strengthen the retraining and learning in nursing personnel and the supervision of the writing of nursing records, so as to ensure the writing quality of nursing records.