| 外科护理文件书写存在的问题及对策 |
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| 引用本文： | 黄小萍,梁丽军,梁卫洁,马庆欢.外科护理文件书写存在的问题及对策[J].家庭护士,2008,6(1):57-59. |
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| 作者姓名： | 黄小萍 梁丽军 梁卫洁 马庆欢 |
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| 作者单位： | 中山大学附属第一医院，中山大学附属第一医院，中山大学附属第一医院，中山大学附属第一医院 |
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| 摘 要： | 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。
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| 关 键 词： | 护理文件 法律意识 质量控制 网络 |
| 文章编号： | 1672-1888（2008）1A-0057-03 |
| 收稿时间： | 2007-11-06 |
Problems existed in surgical nursing files writing and its strategies |
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| Huang Xiaoping, Liang Lijun, Liang Weijie, et al.Problems existed in surgical nursing files writing and its strategies[J].Family Nurse,2008,6(1):57-59. |
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| Authors: | Huang Xiaoping Liang Lijun Liang Weijie |
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| Abstract: | 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. |
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| Keywords: | nursing files legal consciousness quality control network |
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