浅谈基层医院护理文书书写中常见缺陷原因分析及对策

随着<医疗事故处理条例>实施以来,护理文书在医疗事故争议中,也倍受人们关注.因此,提高护理文书书写的质量,对于公正判定医疗事故责任具有重要意义[1].笔者通过对在架病历和终末病历的检查,对查出问题进行原因分析及整改,针对性地组织学习护理文书书写规范及质量讲评,加强护理文书质量控制,以提高基层医院护理文书的书写质量.因此,通过分析护理文书书写中产生问题的原因,有针对性地采取措施解决问题,可以有效提高护理文书书写质量,同时减少因书写中出现失误而导致的护理纠纷.     

浅谈基层医院护理文书书写中常见缺陷原因分析及对策

随着《医疗事故处理条例》实施以来,护理文书在医疗事故争议中,也倍受人们关注。因此,提高护理文书书写的质量,对于公正判定医疗事故责任具有重要意义[1]。笔者通过对在架病历和终末病历的检查,对查出问题进行原因分析及整改,针对性地组织学习护理文书书写规范及质量讲评,加强护理文书质量控制,以提高基层医院护理文书的书写质量。因此,通过分析护理文书书写中产生问题的原因,有针对性地采取措施解决问题,可以有效提高护理文书书写质量,同时减少因书写中出现失误而导致的护理纠纷。     

手术患者护理文书质量分析及对策

护理文书是护士对患者的病情观察和实施护理措施的原始文字记录。临床护理质量在护理文书记录质量中得以体现。质量管理控制科通过对护理文书终末质量的检查及现场环节质量的监控,从护理文书记录中寻找和发现临床护理工作的缺陷,并及时将质控信息反馈于临床,促进临床护理质量的不断提升。手术患者因病情重、变化快,要求观察、记录内容多,因此,手术患者的护理质量始终被视为质控的重点。现将我院2010年1至6月和2011年1至6月外科护理文书质量抽检情况报告如下。1资料与方法     

急诊抢救留观护理记录书写缺陷分析与对策

笔者抽取2009年4月～12月急诊抢救留观护理记录400份,按时间先后分为学习前及学习后各200份,学习前后均依照有关规定及标准进行抢救留观记录缺陷调查分析,比较留观记录缺陷,结果学习后护理记录书写质量明显高于学习前,由此可见加强规范的质控和培训,增强了护士的法律意识,树立抢救留观护理记录书写质量的责任感,提高了护理记录的书写质量。     

急诊抢救留观护理记录书写缺陷分析与对策

笔者抽取2009年4月～12月急诊抢救留观护理记录400份,按时间先后分为学习前及学习后各200份,学习前后均依照有关规定及标准进行抢救留观记录缺陷调查分析,比较留观记录缺陷,结果学习后护理记录书写质量明显高于学习前,由此可见加强规范的质控和培训,增强了护士的法律意识,树立抢救留观护理记录书写质量的责任感,提高了护理记录的书写质量.     

浅析制约电子病历发展的主要问题

电子病历(Computer-based Patient Record．简称CPR)是病历未来发展的方向，但目前存在着法律地位的确立、规范标准的制定、可行技术的应用等主要问题。要解决法律、标准、技术问题，必须进行积极的探索研究，同时也需要得到全社会的关注，尽快制定、实施、开发相应的法律、标准和技术，推动电子病历的健康发展。     

产科护理工作中常见的法律问题分析及防范措施的应用

目的 探讨产科护理中常见法律问题及防范措施.方法 抽取我科18名产科护理人员进行问卷调查,调查完毕后总结问卷进行分析,并提出可行的防范措施.结果 18名产科护理人员存在4种法制观念的认识误区.结论 产科护理人员存在的4种法制观念的认识误区分析后总结出4种常见法律问题及5种防范措施.     

护理缺陷的产生与管理对策

为了严防护理缺陷和纠纷的发生,护理管理者应努力从规范制度、服务流程改进、人员培训、设备维护等方面识别和评估护理服务中各个环节的不安全隐患,研究和探讨护理安全风险管理与防范的程序和重点,制定出护理安全管理防范目标,加强风险防范管理及效果评价,努力将护理缺陷降到最低点,从而为患者提供安全、及时、高效的护理服务。     

北京地区心理门诊从业人员生活质量和CPI分析

目的：调查北京地区心理门诊从业人员的生活质量和个性特点，探寻整体心理健康状况。方法：采用生活质量综合评定问卷（GQOLI-74）和中国修订加利福尼亚心理调查表（CPI-RC），对北京高校和三甲医院心理门诊从业人员进行调查。结果：心理门诊从业人员整体在生活质量、心理功能和主观满意度上。评价均高于对照组。总体的进取能力、社交性、通情、独立成就、智力效率、心理感受性和灵活性分值较高．自我实现水平高。结论：从业人员整体生活质量好。主观满意度高；整体心理健康状况较好，心理成熟度较高。     

Electronic Versus Paper-Based Assessment of Health-Related Quality of Life Specific to HIV Disease: Reliability Study of the PROQOL-HIV Questionnaire

Background

Electronic patient-reported outcomes (PRO) provide quick and usually reliable assessments of patients’ health-related quality of life (HRQL).

Objective

An electronic version of the Patient-Reported Outcomes Quality of Life-human immunodeficiency virus (PROQOL-HIV) questionnaire was developed, and its face validity and reliability were assessed using standard psychometric methods.

Methods

A sample of 80 French outpatients (66% male, 52/79; mean age 46.7 years, SD 10.9) were recruited. Paper-based and electronic questionnaires were completed in a randomized crossover design (2-7 day interval). Biomedical data were collected. Questionnaire version and order effects were tested on full-scale scores in a 2-way ANOVA with patients as random effects. Test-retest reliability was evaluated using Pearson and intraclass correlation coefficients (ICC, with 95% confidence interval) for each dimension. Usability testing was carried out from patients’ survey reports, specifically, general satisfaction, ease of completion, quality and clarity of user interface, and motivation to participate in follow-up PROQOL-HIV electronic assessments.

Results

Questionnaire version and administration order effects (N=59 complete cases) were not significant at the 5% level, and no interaction was found between these 2 factors (P=.94). Reliability indexes were acceptable, with Pearson correlations greater than .7 and ICCs ranging from .708 to .939; scores were not statistically different between the two versions. A total of 63 (79%) complete patients’ survey reports were available, and 55% of patients (30/55) reported being satisfied and interested in electronic assessment of their HRQL in clinical follow-up. Individual ratings of PROQOL-HIV user interface (85%-100% of positive responses) confirmed user interface clarity and usability.

Conclusions

The electronic PROQOL-HIV introduces minor modifications to the original paper-based version, following International Society for Pharmacoeconomics and Outcomes Research (ISPOR) ePRO Task Force guidelines, and shows good reliability and face validity. Patients can complete the computerized PROQOL-HIV questionnaire and the scores from the paper or electronic versions share comparable accuracy and interpretation.     

Development and validation of an electronic version of the Rhinoconjunctivitis Quality of Life Questionnaire

BACKGROUND: As clinicians and pharmaceutical companies move from paper versions of health status questionnaires to electronic versions, it cannot be assumed that adaptations to other media will produce valid data. AIMS: The aims of this study were to (1) adapt the Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ(S); standardized version], for the Palm Treo 650, (2) test the device for ease and accuracy of understanding and (3) examine the validity of the electronic version by comparing it with the original paper version of the RQLQ(S). METHODS: Seventy adults with current rhinoconjunctivitis symptoms completed the electronic and paper versions of the RQLQ(S). They were randomized to complete either the paper or the electronic version first. After a 2-h break, they completed the other version. RESULTS: Concordance between paper and electronic versions for the overall RQLQ(S) score was acceptable with an intraclass correlation coefficient of 0.95 and there was no evidence of bias (P = 0.13). Concordance for the seven individual domains ranged from 0.86 to 0.94. A small but significant bias was observed in the activity and sleep domains (P = 0.02). Completion times were quicker with paper (4.1 vs 4.9 min, P < 0.0001). About 51% of patients preferred electronic, 17% preferred paper and 31% had no preference. CONCLUSIONS: This electronic version of the RQLQ(S) was easy for patients to use and the concordance between paper and this version on the Palm Treo 650 provides evidence of the validity of this electronic version.     

老年人戊肝临床特点分析

目的探讨老年人戊型病毒性肝炎（戊肝）的临床特点。方法对老年人戊肝60例及非老年人戊肝64例作对照分析,比较两组之间的临床特点。结果老年戊肝患者组急性黄疸型比率和重型肝炎发病率,重叠感染率,合并基础疾病率,病死率,病程,胆红素水平,并发症（感染,腹水及感性脑病）的发生率均明显高于非老年组;而ALT,胆固醇,白蛋白及凝血酶原活动度要低于非老年组。两组在性别及临床表现上无明显差异。结论老年人戊肝不少见,病程长,病情重,预后不佳。     

成人下颌第三磨牙阻生和先天性缺失的调查

本文对620侧成人下颌第三磨牙进行了口腔肉眼检查,对无下颌第三磨牙进行了 X 线拍片检查:发现阻生牙314侧,阻生率为50.6%:先天缺失133侧,缺失率为21.5%。阻生率与先天缺失率均无性别差异。     

Amplatzer封堵器治疗房间隔缺损的方法学研究和临床疗效评价

目的　采用数字影像测量球囊直径指导Amplatzer封堵器植入 ,评价这一方法的可靠性及近期临床疗效。 方法　 30例病人 ,经胸壁超声心动图 (TTE)检查证实为先天性心脏病房间隔缺损 (ASD)。在X线透视及经食管超声心动图监视下 ,采用数字影像测量球囊直径指导选用适宜直径的Amplatzer封堵器封堵ASD。术后 3天、3个月及 1年分别行经胸超声心动图 (TTE)、心电图及X线检查评价治疗效果。结果　 30例ASD术中TEE测定直径、球囊伸展直径和封堵器直径分别为 10 30mm [(2 0 .3± 5 .0 )mm]、10 34mm[(2 1.8± 6 .1)mm]和 12 38mm [(2 4 .8± 6 .4 )mm]。 30枚封堵器植入均获得成功 ,一次封堵成功率 85 %。 30例均完成 3个月随访 ,TTE显示ASD完全闭合 ,右心房、心室缩小 ;其中 2 0例完成术后 1年随访 ,未见残余分流及再通。结论　用数字影像测量球囊直径指导Amplatzer封堵器植入治疗ASD是一种简单可靠方法     

Translating the IHE Teaching File and Clinical Trial Export (TCE) Profile Document Templates into Functional DICOM Structured Report Objects

The Integrating the Healthcare Enterprise (IHE) Teaching File and Clinical Trial Export (TCE) integration profile describes a standard workflow for exporting key images from an image manager/archive to a teaching file, clinical trial, or electronic publication application. Two specific digital imaging and communication in medicine (DICOM) structured reports (SR) reference the key images and contain associated case information. This paper presents step-by-step instructions for translating the TCE document templates into functional and complete DICOM SR objects. Others will benefit from these instructions in developing TCE compliant applications.     

济南市老年人生活质量与心理卫生状况调查分析

目的：为了解济南市老年人生活质量与心理卫生状况。方法：采用心理咨询与体查方法对60岁以老年人进行测查。结果：影响老年人身心健康的主要因素有：生活习惯，慢性病，日常生活自理能力，经济收入，居住条件，老年期性心态，老年人的心理特点和负性生活条件，结论：改善老年人的生活条件，改变不良习惯，加大社会保险力度，发展社区医疗卫生工作是提高老年人健康水平，改善老年人生活质量的关键。     

带感觉神经的小腿内侧皮瓣的解剖及其在修复足跟部软组织缺损中的应用

目的:报道带感觉神经的小腿内侧皮瓣的解剖转移修复足跟部皮肤缺损。方法:从1986年1月～1997年12月共用上述皮瓣修复足跟部软组织缺损52例。皮瓣最小8cm×10mm,最大12mm×18cm。所带感觉神经与足背外侧皮神经吻合。结果:50例皮瓣全部成活,2例皮瓣尖端坏死。获随访的40例,时间6个月～9年,皮瓣感觉、外观及功能恢复好。结论:此皮瓣血供丰富,供压面积大,带感觉神经。手术操作简便,是修复足跟部皮肤缺损的理想皮瓣。     

临床输血病历质量调查分析

调查医院输血病历存在的问题,分析不合理原因,提高临床输血质量。方法 以《病历书写基本规范》《医疗机构临床输血管理办法》《临床输血技术规范》《医院输血管理检查评分表》为依据,随机抽查我院2017年1月~12月临床用血科室的466份输血病历,对输血有关记录的完整性、输血适应证、输血不良反应进行分析。结果 共抽取病历466份,其中手术科室224份,非手术科室242份;手术科室与非手术科室输血相关记录不合格率相比较,差异有统计学意义（P＜0.05）,以输血治疗同意书记录缺陷为主;非手术科室输血合理率（93.80%）高于手术科室（89.73%）,但差异无统计学意义（P＞0.05）。结论 部分临床医生对输血病历质量的重要性认识不足,医院应加强对临床输血病历质量的检查、分析和改进,加强医务人员输血知识的培训,不断提高临床输血的科学性和规范性。