外科护理文件书写存在的问题及对策

[目的]提高护理文件的书写质量,防范医疗纠纷发生。[方法]以方便抽样方式抽查我院外科110份护理文件,对存在的问题进行总结分析。[结果]护理记录缺陷可分为6类:缺项及漏项;病情记录不全面,缺乏联贯性;书写不规范;主观判断,记录欠真实;未及时修改护嘱;医护记录不一致。[结论]提高护理人员的法律意识和责任意识,规范和培训护理文件的书写,开展多层次的业务培训和学习,建立护理文件质量控制网络,对提高护理文件的书写质量,防范医疗纠纷发生非常必要。

Problems existed in surgical nursing files writing and its strategies

Objective:To improve the quality of nursing files writing and to prevent the occurrence of medical disputes.Methods:A total of 110 pieces of surgical nursing files in our hospital were checked randomly by convenient sampling.And existed problems were summed up and analyzed.Results:Nursing record defects can be classified into six categories including incomplete items and omission items,un-allround pathography and lack of consistency,non-standard writing,subjective judgment and unreal record,not modifying nursing order in time,and disparity records between doctors and nurses.Conclusion:It is necessary to improve legal and responsible consciousness of nursing staffs,to standardize nursing files writing,to carry out multi-level professional training and learning and to construct nursing files quality control network for both enhancing the quality of nursing files writing and the prevention of medical disputes.