重症护理记录缺陷的研究分析与防范措施

目的研究重症护理记录缺陷,分析其中的法律风险,有针对性的采取防范措施,提高病案书写质量。方法根据《护士条例》、《侵权责任法》等相关法规设计检查表格,抽查重症护理记录单,总结记录缺陷,分析法律风险及原因,探讨防范措施。结果 200份重症护理记录单中,47份出入量记录错误、38份未正确执行医嘱、32份未执行正确医嘱、14份未履行通知义务、19份不正确的修改记录、21份医护记录不一致,严重的记录缺陷存在很大的法律风险。结论重症护理记录单是医疗纠纷发生时的重要证据,应加强病历文书的质量管理,提高重症护理记录单的书写水平。

Analysis and Preventive Countermeasures about Intensive Care Records Defects

Objectives this article researches defect of intensive care records and analyzes its legal risk,adapting preventive countermeasures and improving medical records quality.Methods It designs examination forms related regulations according to Nurse Regulations and Tort Liability Law.Intensive care records are randomly examined for summarizing defects,analyzing legal risk and reasons and discussing preventive countermeasures.Results There are 200 intensive care records are examined,in which 47 copies have error about number record;38 copies incorrectly implement doctor’s advice;32 copies do not implement correct doctor’s advice;14 copies do not implement informed obligation;19 copies incorrectly revise records;medical and nurse’ records of 21 copies record are not unify.The severe records defects exists huge legal risk.Conclusions Intensive care record is vital evidence during medical tangle that should strengthen quality management of medical records and improve writing level of intensive care records.