护理病历记录缺陷分析及对策  

作　　者：魏小惠 

机构地区：[1]五华县中医医院,广东五华514400

出　　处：《现代临床护理》2005年第4期56-58,共3页Modern Clinical Nursing

摘　　要：目的分析护理病历记录书写中存在的问题,并提出对策。方法采用整群抽样法,抽取800份护理病历,对其存在的质量缺陷进行总结、归类和分析。结果护理记录主要存在有156处缺陷:不能体现护理行为30处、不能体现护理动态过程有23处、真实性存在缺陷42处、记录不全13处、记录连续性差25处、没有体现因人施护和因需施护12处,医护记录时间不统一11处。结论必须加大护理记录质量的检查和管理,重视护理人员的法律知识和人文知识的学习,以提高护理记录的质量。Objective To analyse defects in nursing recoyds and to raise homologous strategies. Methods We took 800 nursing histories out from the total ones all year at random monthly, based on the evaluation standard of nursing records, and then summarize,sort out,analysis for defects among the records. Results 156 defects were found in 800 nursing records, emphasis can not be raised out obviously in 30 records, document can not be written on time in 23ones , and deviation was found in llones between doctors and nurses,and un-true records were found in 42 ones,and un-overall records were found in 13 ones. Conclusion it ensured to raise quality of nursing record by writing normalization ally, managing ,training in profession and communication betttween doctors and nurses.

关 键 词：护理记录 缺陷 护理管理 

分 类 号：R47[医药卫生—护理学]