手术护理记录单中常见问题及对策

目的分析手术护理记录单在书写中存在的问题,查找原因并及时予以纠正,有效提高护理记录单的书写质量。方法通过对6853份手术室护理文件进行检查,将存在的问题进行分类、分析。并通过加强学习、规范书写、加大检查力度与绩效挂钩等多种方法加以解决。结果共检查6853份。其中病案3000份,运行病历3853份。查出存在问题的手术护理记录单53份,手术物品清点单38份,占所检查护理文件的1.32%。影响手术室护理文件书写质量的主要问题是项目填写不全或空项、记录不及时、代签名、有涂改等问题。结论通过发现问题,不断查找原因,有针对性地采取措施,不断规范护理人员临床医疗护理行为,提高护理记录书写质量。

Problems and Countermeasures in Surgical Care Records

Objective Analysis the problems of Surgical Care record, and find out the reasons and correct timely, in order to improve the quality of Surgical Care record. Methods check 6853 Surgical Care Records, classify and analysis the problems. Results There are 53 records with problems, ac- counting for 1.32%. The main problem of writing are filling incomplete or empty, not timely, signature instead, altering. Conclusions For the prob- lems identified, we should take corresponding measures to Improve the quality of Surgical Care Records.