关注患者安全 加强护理记录内涵质量管理简

目的对护理记录中部分涉及患者安全的内容进行检查分析，提高护理记录内涵质量管理。方法依据国家卫生部颁发的《病历书写基本规范（试行）》的有关规定，结合医院护理记录书写要求，对患者跌倒、压疮、输血、医嘱执行、特殊记录等5项内容进行检查。结果问题较多的是跌倒及压疮评分不准或措施不到位。结论通过部分涉及患者安全护理记录的检查，体现出护理记录检查不能流于形式框架的表面现象，应在护理内涵质量建设中发挥更大的作用。

Pay Close Attention to the Safety of the Patients and Strengthen the Connotation Quality Management of Nursing Writing

Objective To examine and analyze the contents related the safety of the patients in the nursing writing, improve its connotation quality management. Method To conduct an investigation on five items such as falling, bedsore, transfusion, implementation of doctors＇ advice and special recordings according to the ＂Fundamental Rules of Medical Records Writing＂ announced by the National Health Ministry combined with the writing requirements of the nursing writing of the hospital. Result The most problems were falling and inaccurate bedsore score. Conclusion Through the investigation of the contents related the safety of the patients in the nursing writing, we found that the investigation could not stay on the surface phenomenon of the form or frame, but also play a more important role in the construction of the connotation quality of the nursing.