护理文件书写中存在的问题及缺陷因素分析  

Analysis in Questions and Deficient During Writing in Nursing Document

作　　者：邢彩霞[1] 

机构地区：[1]内蒙古自治区医院护理部,内蒙古呼和浩特010017

出　　处：《内蒙古医学杂志》2007年第8期1011-1013,共3页Inner Mongolia Medical Journal

摘　　要：目的:分析护理记录单书写存在的问题,提高护理记录质量。方法:从住院病历中随机抽取护理记录784份,由护理质控组进行质量评价。结果:护理记录单书写中存在的缺陷依次为内容缺乏连续性、记录治疗内容多护理内容少、缺乏个性化、语言表达不准确、记录不及时、不全面、使用医学术语不恰当。结论:加大护理记录单的检查与管理力度,重视护理人员的法律知识、病历书写知识、专业知识、质量监控知识和文化素质的培训,以规范护理记录的书写。　Objective：To analyze the questions of writing nursing records,for improving quality of nursing records.Methods： 784 nursing records randomly selected from medical records were evaluated by nursing quality control group.Results： The questions in nursing records included discontinuous content,lack of nursing content,less individuation,inaccurate express,overdue and uncomplete records and inaccurate medical terms.Conclusion： The examination and monitor in nursing records,training in law knowledges,writing technique in medical records,specialized knowledge,informations about quality control and culture ability should be emphasized.

关 键 词：护理记录 缺陷 分析 

分 类 号：R47[医药卫生—护理学]