医护记录不一致性的原因分析与改进方法

目的　了解医护文书书写中不一致表现及潜在的法律问题 ,探讨医护文书一体化的可行性。方法　将医、护记录以主观、客观资料划分 ,采用医护文书一体化记录。结果　一体化记录加强了医护合作 ,减少了医护记录不一致的错误 ,病程记录更系统、更完整、更合理。结论　医、护文书一体化是医疗文书书写中的一种新尝试 ,值得进一步探讨与推广。

Analysis of the reasons and countermeasure of the discordance in medical and nursing records

Objective To investigate the manifestation of the discordance in medical and nursing records and the potential problem of law, as well as to explore the feasibility of the synthesis of medical and nursing documents.Method The clinical records were classed into subjective and objective data, and then perform the synthesis of medical and nursing records.Results The synthesis of medical and nursing records reduced the errors of the discordance in medical and nursing records, and the records of illness course became more systematic, integrated and reasonable.Conclusion Synthesis in medical and nursing records is a new attempt in the writing of medical documents and it deserves to be researched further and spread out.