护理记录单书写存在的问题及原因

《医疗事故处理条例》规定,病人有权复印体温单、医嘱单、护理记录单等,它们在医疗事故和纠纷处理中具有重要的法律意义。护理记录单书写从形式到内容均面临许多问题,如医护记录时间不统一,护理记录书写不及时、不完整、字迹不清楚、内容不连贯、重点不突出等。其原因有医护之间缺乏沟通;病情观察不严密;记录简单不准确;法制观念淡薄等。

The Problems and the Reasons in the Writing of Nursing Records

The regulation on the handling of medical accident says that the patients have rights to copy temperature records,doctor's advice records and nursing records etc.They are very important in medical accident and dispute.To analyze the problems in the writing of nursing records from form to contents,which including that : inconsistency of time and contents,inaccuracy and untimely of nursing records,unclear handwriting,lack of coherence in contents,lack of key points etc.The main reasons in the writing of nursing records were as follows: lack of communicate between doctors and nurses,observing the state of an illness non-rigorously,too simple or incorrect records,too shallow conception of law.In this article,the author summary the problems and the reasons in the writing of nursing records,in order to help nursing staff to improve highly the quality of records.