护理记录书写中存在的问题分析与对策

2002年9月1日《医疗事故处理条例》实施，护理记录纳入住院患者的病历中。护理记录是对患者住院全过程进行客观、真实、准确、及时、完整的记录；它不仅反映临床护理质量、护理水平，而且也反映出护士观察问题、分析问题及解决问题的能力，为总结临床护理工作经验、护理科研及教学、分析医疗护理事故提供有效的资料；是一份完整病案的重要组成部分。我们随机抽取2007年6月-2007年12月全院6个病区300份护理记录，根据《医疗事故处理条例》、《病历书写基本规范》及北京市护理质量控制与改进中心《护理文件书写规范》的规定，结合本院护理记录书写规范进行检查、分析，以针对存在的问题，寻求改进对策。     

护理记录缺陷分析与干预措施

由卫生部和国家中医药管理局制定的《病历书写基本规范(试行)》从2002年9月1日正式施行。其中涉及护理工作的条款有多项，特别是对护理记录的书写做出了较具体的要求。《医疗事故处理条例》又规定，患者有权复印客观病历资料，其中包括护理记录单。这就给护士提出了较高的要求，必须客观、真实、准确、及时、完整地记录患者疾病发生发展与诊疗护理的全过程，以确保医患双方的合法权益，     

一般护理记录单首页的设计

1　资料[根据卫医发 2 0 0 2 ]90号关于印发《病历书写基本规范 (试行 )》文件中的第三章住院病历书写要求及内容的第十六条第三十二款 ,住院病历内容必须包括护理记录 ,护理记录分为一般患者护理记录和危重患者的护理记录。在此文件发布以前临床上只记录危重患者的护理记录 ,而一般患者没有护理记录 ,根据文件精神笔者以表格形式设计出《一般护理记录单首页》见表 1,发放表格 5 0 0份分别在骨科、外科、内科进行临床实践 ,受到临床护理人员的好评。表 1　一般护理记录单首页　　床号　　　　姓名　　　　　　年龄　　　　　性别　　　　住…     

护理记录缺陷存在法律问题分析及对策

随着《医疗事故处理条例》颁布以及《病历书写基本规范实施细则》、《医疗护理技术操作常规》下发,患者维权意识的增强,对医疗护理工作提出了更高的要求,患者投诉呈上升趋势。因此在医疗护理过程中,护理记录的书写质量,规范护理记录书写标准,完善护理记录控制制度非常重要。因为护理记录是护理人员对患者住院期间的整个护理过程的客观记录,是医疗纠纷的重要法律依据,对护理记录中存在缺陷进行分析并采取相应措施是势在必行的。     

2844份护理病历缺陷分析及对策

目的分析归档病案护理病历存在问题，进一步提高护理病历监控质量。方法根据2003年广东省卫生厅制定的《广东省病历书写规范》标准及医院管理年活动中《护理病历评分标准》，对我院2007年1～6月份的12，402份护理归档病案进行终末质检。结果2844份护理病历存在缺陷，缺陷率为22．94％，其中护理记录及体温表是护理病历书写的薄弱环节。结论必需重视护理病历的规范化书写，以保障医疗护理活动中患者和护士双方的合法权益。     

100份手术后护理记录内容分析

手术后护理记录是护士对手术后病人进行病情观察和实施护理措施的原始文字记载。继2002年卫生部、国家中医药管理局出台了《病历书写基本规范（试行）》（以下简称《规范》）后，广西壮族自治区卫生厅医政处新编了《广西壮族自治区医疗机构病历书写规范手册（内部资料）》（以下简称《手册》）。根据其《护理文件书写规范及要求》，我院使用了一般患者护理记录单和危重患者护理记录单。为了解我院外科护士在使用新护理记录单后，手术后护理记录内容是否完整，本文对100份手术后护理记录内容进行了分析，现将结果报告如下。     

护理文件书写存在的问题原因分析及对策

护理文件是病历的重要组成部分，是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，具有法律效力的。从2002年10月1日起按照卫生部和国家中医药管理局制定的《病历书写规范》和《四川省护理文件书写规范》（试行）要求。我院对护理文件书写进行了规范和改进，并应用于临床。实行举证责任倒置，赋予了护理文件记录新的内涵，成为处理医患纠纷的法律依据。但是在临床工作中由于种种原因，护理文件在实际记录中仍存在着一系列的问题，     

850份终末病历护理记录缺陷分析及对策

为适应新的《医疗事故处理条例》,迎接病历公开对护理学科带来的挑战,减少护理记录缺陷引起的纠纷,我院护理部根据《医疗事故处理条例》及《山东省医疗护理文书书写规范》的要求,修订了《护理文书书写与管理补充规定》与《护理病历评分标准》,并对全院护理文书书写质量进行督导与检查,针对存在的问题及时反馈与整改。现将850份终末病历中护理记录存在的问题进行分析,探讨干预措施,提高护理病历书写质量。     

护理记录缺陷分析

20 0 2年 9月 1日起实施的《医疗事故处理条例》规定 ,在发生医疗事故争议时 ,患者有权复印或复制客观病历 ,护理记录在鉴定中亦起着至关重要的作用 ,要求护理人员书写病历要严格、认真、字迹清楚、无涂改 ,书写有真实性 ,所以各级医院要加强护理管理和提高护士业务水平 ,掌握对患者病情变化的判断能力 ,做到及时、准确记录。1　对象与方法1.1　调查对象　我们对 2 0 0 3年 2月至 2 0 0 4年 2月病历抽查80份进行评估。1.2　方法　采用系统抽样抽取 ,2 0 0 3年 2月至 2 0 0 4年 2月病历 80份 ,按照本院《护理文件书写质量检查表》的要求 ,逐一进行检查对照 ,找出护理文书中的缺陷 ,分析与法律有关的问题。2　结果护理记录中存在着明显的不足 ,见表 1。表 1　 80份病历中护理记录的书写缺陷缺陷份数发生率 (% )护理记录书写不重视 10 12 .5护理记录不够具体明确 14 17.5缺乏连续性 12 153　原因分析3.1　护士对护理记录书写不够认真　认为动笔杆子是医生的事 ,病历书写等医生写完 ,抄一下就可以 ,并没有认真去观察病情变化 ,及时去记录 ,特别是危重病人变化...     

护理病历书写中的问题

2002年9月1日《医疗事故处理条例》实施，2006年12月20日我院组织护理病历书写大比武活动。通过此次活动提高了护士的书写护理病历的质量，规范了护理记录，促进了护理学科的发展。完整及时客观的护理记录是医生诊断和治疗的重要理论依据，是患者的法律依据。在这次护理记录比赛中，对照白山市“医疗文件书写规范”中护理记录的书写要求，发现护理记录中存在一些问题，现分述如下：     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

BLOOD PRESSURE CHANGE WITH AGE IN SALT-SENSITIVE TEENAGERS

Objective To observe blood pressure change with age in salt-sensitive teenagers whose salt sensitivity were determined by repeated testing.Methods Salt sensitivity was determined through intravenous infusion of normal saline combined with volume-depletion by oral diuretic furosemide in 55 teenagers. After five years, salt sensitivity was re-examined and subject blood pressure was followed up. Blood pressure changes in salt-sensitive teenagers were compared to that of non-salt sensitive teenagers over five years.Results After 5 years, the repetition rate of salt sensitivity determined by intravenous saline loading is 92.7%. In teenagers with salt sensitivity on the baseline, both the systolic blood pressure increments and increment rates were much higher than non-salt sensitive teenagers (12.7±12.1 mmHg vs. 2.8±5.2 mmHg, P＜ 0.01; 12.2%± 12.0% vs. 2.5% ±4.4%, P＜ 0.001,respectively). There was a similar trend for diastolic blood pressure (8.4 ± 6.4 mmHg vs. 3.7 ± 6.4 mmHg, P = 0.052; 13.2% ±10.6 % vs. 6.8%± 10.1%, P = 0.053, respectively).Conclusions Salt sensitivity determined by intravenous saline loading showed good reproducibility. Blood pressure increments with age were much higher in salt-sensitive teenagers than non-salt sensitive teenagers, especially in terms of systolic blood pressure.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.     

Scientific principles and rigorous processes should be followed in developing clinical guidelines for therapeutic interventions of integrative medicine

A clinical guideline for the therapeutic interventions of integrative medicine may be defined as a written document which states a series of recommendations on therapeutic interventions of integrative medicine for a special disease or condition. The guideline may provide assistance to medical professionals in making clinical decisions aimed at improving the clinical outcome of patients and reducing the costs of medical care（~＇4~. Recommendations issued by a guideline should be based on the best available evidence in both Western and Chinese medicine. For fulfilling this purpose, the development of clinical guidelines for therapeutic interventions in the field of integrative medicine should follow scientific principles and undergo a rigorous processes.