一般护理记录存在的问题与对策

新的《医疗事故处理条例》及《病历书写基本规范》已经从 2002年 9月 1日开始实施。《病历书写基本规范》要求护士对病人住院期间的护理全过程必须客观、准确、真实、及时、完整地记录, 《医疗事故处理条例》中规定所有的护理文件都是病人或家属随时复印或复制的客观资料。病历书写客观、真实、及时、准确、完整, 以及保存的完好性, 是判断护理行为正确、及时、有效、安全的主要依据。随着《医疗事故处理条例》的实施及广大人民群众的法律意识的提高, 医疗纠纷日渐上升, 故护理记录的真实、客观、完整, 对保护护士及病人的合法权益就显…     

护理纠纷的防范

“医疗纠纷”是指医患双方对医疗后果及其原因产生分歧而向司法机关或卫生行政部门提出控告所引起的纠纷[1] 。新的《医疗事故处理条例》开始实施 ,使护理人员的压力越来越大 ,担忧也越来越多。如何保证护理安全 ,防范医疗事故 ,减少护理纠纷 ,是摆在每位护理人员面前的重要课题。我院从 2 0 0 2年 4月起 ,采取了有效措施 ,全年无护理纠纷发生。现将具体做法报告如下。1　充分认识防范护理纠纷的重要性护理部组织全院护士学习《医疗事故处理条例》及考试 ,使护士深刻理解条例的精神实质 ,认识到防范护理纠纷的重要性 :①保证病人的安全 ;②…     

一般护理记录存在的问题与对策

新的《医疗事故处理条例》及《病历书写基本规范》已经从2002年9月1日开始实施。《病历书写基本规范》要求护士对病人住院期间的护理全过程必须客观、准确、真实、及时、完整地记录，《医疗事故处理条例》中规定所有的护理件都是病人或家属随时复印或复制的客观资料。病历书写客观、真实、及时、准确、完整，以及保存的完好性，是判断护理行为正确、及时、有效、     

新形势下加强护理安全管理的对策

《医疗事故处理条例》(以下简称《条例》)于 2 0 0 2年 9月 1日开始实施 ,在新的形式下 ,护理部如何做好安全护理管理 ,有效防范医疗事故的发生 ,更好地保障护士和病人的合法权益 ,减少医疗纠纷是各医院护理管理部门都在探讨的问题。我院护理部按照《条例》和其他相关法律的有关规定 ,研究新对策 ,认真做好相应的管理和预防措施 ,现介绍如下。1　加强法律知识学习 ,全面理解《条例》新要求 ,提高法律意识、安全意识、风险意识　　认真学习《条例》及配套文件 ,深刻领会《条例》内涵 :《条例》刚宣布实施时 ,部分护理人员出现过分担心 ,而另…     

危重患儿护理记录存在的问题与原因分析

护理记录是护理人员对病人病情观察和实施护理的原始文字记载,是护士根据医嘱和病情对危重患儿住院期间护理过程的客观记录。它不仅衡量护理质量,提供诊疗依据,同时也是《医疗事故处理条例》所规定的法定证据。《医疗事故处理条例》第10条规定:病人有权复印体温单、医嘱单、护理记录单等。这些记录记载了病人接受治疗和护理的全过程,在医疗事故和纠纷处理中具有重要的法律意义。危重患儿护理记录从形式到内容均存在着许多问题,涉及的原因也很多,现总结如下。1存在问题1.1医护记录不一致1.1.1时间不统一医护记录时间不统一,医生开医嘱与护士…     

基层医院护理记录书写缺陷及对策

护理记录是护士根据医嘱及病情对病人住院期间治疗护理过程进行客观、真实、及时、完整的记录[1-5]。《医疗事故处理条例》明确规定:病员有权复印病历资料[6],这就要求护理人员必须高度重视临床护理记录。基层医院由于地理位置偏     

护理记录书写规范化的探讨

《医疗事故处理条例》颁布以来,护理记录作为护士对患住院期间护理过程的客观反映,越来越受到广大护士和各级护理管理的重视。《医疗事故处理条例》将护理记录纳入患有权复印的客观资料的范畴,护理记录也就成为处理医疗事故的重要法律书^[1]。现对当前护理记录中存在的问题作一总结,并探讨相应的对策。     

护理记录规范管理

《病历书写基本规范 (试行 )》规定 :护理记录是指护士根据医嘱和病情对病人住院期间护理过程的客观记录。根据 2 0 0 2年 9月 1日起实施的《医疗事故处理条例》第十条规定 ,病人有权复印或复制门诊病历、住院志、体温单、医嘱单、护理记录及国务院卫生行政部门规定的其他病历资料。这些医疗文件记录是医务人员在医疗护理过程中形成的书面记录 ,记载了病人接受治疗和护理的全过程 ,在医疗事故和纠纷的处理中具有重要的法律意义[1,2 ] 。因此 ,护理记录必须与医疗记录一致 ,客观真实地反映病人的病情变化、医疗护理措施的落实情况和实施后的…     

护理记录内容如何体现新要求

2002年国务院颁发的《医疗事故处理条例》(以下简称《条例》)以及其配套文件《病历书写基本规范(试行)》(以下简称《规范》)对护理记录提出了新的要求。《规范》明确规定：护理记录是把病人发生的状况、症状或发生的事情加以说明，以及护士为此按照操作规程所执行的护理活动，病人接受护理后的反应结果，用医学术语表达出来。《条例》     

危重患儿护理记录存在的问题与原因分析

护理记录是护理人员对病人病情观察和实施护理的原始文字记载，是护士根据医嘱和病情对危重患儿住院期间护理过程的客观记录。它不仅衡量护理质量，提供诊疗依据，同时也是《医疗事故处理条例》所规定的法定证据。《医疗事故处理条例》第10条规定：病人有权复印体温单、医嘱单、护理记录单等。这些记录记载了病人接受治疗和护理的全过程，在医疗事故和纠纷处理中具有重要的法律意义。危重息儿护理记录从形式到内容均存在着许多问题，涉及的原因也很多，现总结如下。     

学习《医疗事故处理条例》规范护理记录

目的:规范护理记录,适应《条例》举证,维护医患双方的权利和义务。方法:研究传统护理记录缺陷,制定对策,改革护理记录模式。结果:通过对《条例》的学习,护士增强了自我保护意识,明确了护理行为不但是一种社会责任,还必须受到法律的规范。结论:提高了护理记录书写质量,护理记录客观、真实、准确,适应举证需要。     

护理不安全因素分析与管理对策

目的总结分析护理工作中存在的不安全因素，并提出防范对策。方法根据文献分析总结护理工作中存在的不安全因素，作者认为应对护理人员进行安全、规章制度及职业道德教育，健全和完善各项护理安全质量监控管理制度，规范工作流程，加强规范化培训等管理对策。结果通过护理不安全因素防范管理措施的有效落实，可提高护理人员对护理安全质量的认识及意识，建立良好的护患关系；严守操作规程，遵循护理法规，强化护理行为中的法律意识，增强了法律观念；重视专业理论学习，护理技术操作训练。结论最大限度地消除了护理不安全性及患者的不安全感，既保护了护理人员又维护了患者的权益，保证全程、全员、全面质量管理方案的实施，使护理安全管理制度化、标准化、规范化，真正为患者提供安全、方便、放心、满意的优质服务，有效地预防护理差错事故的发生。     

Impact of Organisational Culture on Use of Scientific Knowledge in Nursing Practice

ABSTRACT The aim of this study was to answer the question: How does organisational culture influence nurses' use of scientific knowledge in practice? The culture of the health care organisation was analysed mainly in terms of professionals (nurses, physicians and managers). All three professional subcultures, medical, nursing and managerial, seem to be very important from the patients' point of view. Nursing subculture has, for example, different philosophy, knowledge and values about the purpose and practices of the work. Despite this, many nurses hold medical norms, values and expectations to be more important than those of their own subculture. Consequently, when caring for patients such nurses act and behave according to medical knowledge and cultural assumptions. The influence of cultural factors on use of scientific knowledge in nursing practice can be classified as follows: (1) the nursing subculture is strong but old-fashioned and conservative, (2) the nursing subculture is weak and nurses are expected to act according to some of the competitive subcultures, (3) the content and construction of the process of work socialisation prevent the application of new scientific knowledge. These results must be confirmed in further empirical studies to determine their general validity for the primary health care system in Finland. The cultural analysis of health care system provides new information about why systematic scientific knowledge has not changed nursing practice as much as expected.     

眼外伤致伤因素的分析及护理随访调查

目的：探讨眼外伤患者护理随访对于医院的重要作用。方法：随机抽取眼外伤出院的100例患者进行问卷调查分析，了解他们对医院就医环境、医疗技术、医疗收费、服务态度等方面的满意度，以及其他方面的意见。结果：患者依从性、对医师、护士角色的认识及满意度较高。结论：护理随访有利于提高患者的依从性和满意度，提升了对医师、护士角色的认同，值得推广。     

Practicing Autonomously: A Comparison of Nurses

Forty-five subjects including community health nurses with baccalaureate nursing degrees, senior-level generic nursing students, and registered nurses in a baccalaureate nursing program were compared on age, years of employment in nursing, and three variables of professional autonomy: nurses' rights and responsibilities, the nurse-patient relationship, and nurses' role in health care delivery. It was predicted that nurses from baccalaureate programs and those practicing in community health nursing would perceive themselves as more autonomous and that age and years of employment in nursing would not appreciably alter perceptions of autonomy. An analysis of variance confirmed the initial prediction at the 0.01 level of significance or better for nurses' rights and responsibilities and their role in health care delivery. A significant negative correlation was obtained between age and nurses' rights and responsibilities for the community health nurses; a significant positive correlation was obtained between years of work experience and nurses' rights and responsibilities for only the registered nurses. This study is perceived as an initial step in a lengthy process aimed at identifying factors that influence nurses' perceptions about professional autonomy.     

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。     

Undertaking the role of patient advocate: a longitudinal study of nursing students

Patient advocacy has been claimed as a new role for professional nurses and many codes of ethics for nurses state that they act as patient advocates. Nursing education is faced with the challenge of preparing nurses for this role. In this article we describe the results of a study that considered the tendencies of a cohort of nursing students at the Kocaeli University School of Nursing to act as advocates and to respect patients' rights, and how their capacities to do so changed (or not) as a result of their nursing education. This longitudinal study used a questionnaire consisting of 10 statements relating to patient care. It was performed both at the start (1998) and at the end (2002) of the nursing training. At the beginning of their course 77 students participated; in the study. After four years, only 55 students participated, the reason for this drop in number being unknown. The questions asked nurses if patients should have: the right to receive health care; the right to participate in the decision-making process about their treatment; the right always to be told the truth; and the right to have access to their own medical records. They were also asked: if quality of life should be a criterion for discontinuing treatment; if patients have the right to die and the right to refuse treatment; if patients should be assisted to die or helped to undergo active euthanasia; and if severely disabled newborn babies should be allowed to die. The student nurses demonstrated considerable insight into contemporary nursing issues and were ready to act as patient advocates. Professional responsibility demands that good nurses advocate strongly for patients' choices.     

开展医护质量月护理主题活动的实践与体会

目的开展医护质量月,以提高医护工作质量,改善服务态度。方法组织开展医疗规章制度学习与考核、“三基”基础理论学习与考核、护理病历讨论、护理技术操作竞赛、护理文书书写质量检查与展评、沟通与礼仪情景竞赛等几大主题活动。结果各项护理质量指标平均达标率和患者满意度得到提高,未发生护理差错和纠纷。结论开展医护质量月活动提高了医护质量,改善了医德医风,保证了医护安全,为构建和谐医患关系起到了积极作用。     

加强血透室护理质量管理与法律意识 减少医疗纠纷

阐述了血透室护理质量管理与法律意识的关系,认为血透室作为特殊人群进行特殊治疗的特殊场所,护理工作与法律的关系密切.血透室护理工作者加强自身素质的培养和提高,严格血透室三查七对一注意制度,杜绝差错事故,提高护理服务质量和专科业务知识水平是防止血透室差错与纠纷的关键,在工作中学法、懂法,在护理行为中守法.在维护病人权益的同时,用法律保护自己的合法权益,避免医疗纠纷,维护正常的医疗秩序.     

Registered Nurses' perceptions of geriatric rehabilitation nursing in three Scandinavian countries

This study describes Registered Nurses' perceptions of geriatric rehabilitation nursing as well as their experiences of working in the rehabilitation of older patients in Denmark, Finland and Norway. The aim was to gain deeper insights into how Registered Nurses think about geriatric rehabilitation nursing and how their perceptions differ in these countries. The data were collected among 600 Registered Nurses using a structured questionnaire with five background items and 88 geriatric rehabilitation nursing items. The response rate was 65%. Data analysis was with SPSS statistical software. Geriatric rehabilitation nursing was experienced as something that required knowledge and experience, patience and creativity, as well as professional skills. The nurses talked with their patients about their rehabilitation goals, but not all nurses were aware of those goals. Progress in the rehabilitation process was evaluated on a daily basis and results were noted in the patients' records. The nurses motivated patients by giving them positive feedback, by preventing pain, by pausing to share with the patients their joy about progress, and by giving the patients the opportunity to cope with daily activities. The Registered Nurses in Denmark were more team oriented and they set out the goals in the patient's records more often than their colleagues did in Finland and Norway.