探讨精神科护理文件规范化书写的管理策略

目的通过分析精神科护理文件书写存在的缺陷,探讨护理文件规范化书写的管理策略,从而提高护理文件书写质量,提升护理安全。方法选择2009年1—6月新入院患者病史及随机抽查长期住院患者病史共360份。对护理文件按照我院护理文件书写标准册进行检查,包括体温单、医嘱单、入院评估单和护理记录单等。结果体温单中存在缺陷58份,占16.1%;医嘱单中存在缺陷45份,占12.5%;一般护理记录单中存在问题160份,占44.4%;其他如约束保护记录单,无抽搐电休克记录单和入院评估单等书写整洁,基本无漏项现象。结论规范护理文件书写是确保护理文件书写质量提高的关键,加强护理人员业务知识、基本技能和法律法规知识培训,强化制度、完善质控管理体系,是提高护理质量降低护理纠纷的必要措施。

Investigation on management strategy in standardized writing of psychiatric nursing records

Objective To analyze the defects of psychiatric nursing records,and to explore the management strategy in standardized writing,thus increasing writing quality and enhancing nursing safety.Methods A total of 360 psychiatric nursing records（temperature sheets doctor′s advice sheets,evaluate sheets,nursing recording sheets,etc.） in our hospital were chosen,including history of new cases from January to June 2009 and randomly selected long-term hospitalized patients.The records were inspected according to the standardized writing of nursing records in our hospital.Results Temperature sheets： 58 records（16.1%） existed defects;Doctor′s advice sheets： 45 records（12.5%） existed defects;General nursing recording sheets： 160 records（44.4%） existed defects.Other records such as protective constraint recording sheets,modified electric convulsive therapy recoding sheets and evaluate sheets were tidy,no items lacked nearly.Conclusion Standardized writing is key to improvement in writing quality of nursing records.It is necessary to strengthen the training of nurses in professional knowledge,basic skills,and laws/regulations knowledge,and improve the quality control system to elevate nursing quality and reduce nursing dispute.