归档病案质控中护理文书缺陷及对策

目的 通过对归档病案护理文书的质量缺陷分析,保证护理文书书写质量,规避医疗纠纷,确保临床护理安全.方法 随机抽取2013年6月-2014年3月出院归档的病案513份,依据护理文书书写检查标准,对护理文书包括护理记录单、医嘱单、体温单等进行检查分析.结果 检出护理缺陷项1816频次,其中护理记录单缺陷项764频次（42.02％）,体温单缺陷项511频次（28.16％）,医嘱单缺陷项420频次（23.15％）,其它缺陷项121频次（6.67％）.结论 护理文书已成为病案组成的重要项目和无法替代的医疗文书.因此,采取强化护理人员法律意识、加强护理人员技能培训与落实质控责任制、合理调配人力资源等措施,有效维护护患双方合法权益,提高护理文书质量规避医疗纠纷的有效保障.

Defects of Nursing Document in the Quality Control of Archived Medical Records and Relevant Countermeasures

Objectives To guarantee the writing quality of nursing documents, avoid medical disputes and ensure the safety of clinical nursing through analyzing the quality defects of nursing document in archived medical records. Methods 513 cases of discharged archived medical records were randomly selected in our hospital from June 2013 to March 2014, then conducted inspection analysis on the items in the nursing documents included nursing records, physician＇s order sheets and temperature sheets according to the inspection standards of nursing documents. Results 1816 items of defects were detected in the nursing documents, in which there were 764 cases of defects items in nursing records sheets, which accounted for 42.02%; 511 cases of defects items in temperature sheets, which accounted for 28. 16%, 420 cases of defects items in physician＇s order sheets, which accounted for 23. 15%, and other defects items accounted for 6. 67%. Conclusions The nursing document had become an important part of medical records which could not be substituted by others. Therefore, we should adopt measures such as strengthen the legal awareness of nurses, enhance the skill training and implementation of quality control responsibility, as well as allocate human resources reasonably, so as to protect the legal rights of both nurses and the patients, and improve the quality of nursing documents to provide effective guarantee for the prevention of medical disputes.