362份危重病患者护理记录缺陷分析及干预的研究  

The analysis on deficiencies of 362 nursing records of critical patients and countermeasures

作　　者：冯美妍[1] 张锡兰[1] 孙伟[2] 徐文伟[3] 

机构地区：[1]山东省青岛市传染病医院一病区,266033 [2]山东省青岛市传染病医院护理部,266033 [3]山东省青岛市传染病医院门诊部,266033

出　　处：《中国护理管理》2006年第4期31-33,共3页Chinese Nursing Management

摘　　要：目的:探讨规范危重病患者护理记录书写应遵循的原则和规范,提高护理病历质量。方法:对362份危重病患者护理记录单存在的缺陷进行统计分析。结果:确定了危重病患者护理记录单的缺陷原因,提出相应的干预措施,保证护理质量和病案的完整性。结论:要加强质量监督,确保护理文书的规范化,以防护理纠纷的发生,便于医院内病案实行统一规范化。Objective： To explore the standard of nursing records of critical patients. Methods： 362 nursing records of critical patients have been investigated. Results： the reasons for deficiencies have been found and countermeasures have been proposed. Conclusion： The quality control of nursing records of critical patients should be strengthen in order to standardize nursing record and prevent nursing dispute.

关 键 词：危重病 护理记录 缺陷 质量控制 医院 

分 类 号：R47[医药卫生—护理学] R197.32[医药卫生—临床医学]