从护理文件缺陷谈医患纠纷防范  

The Protection of Medical Disputes from the Limitations in the Nursing Documents

作　　者：郭杰 

机构地区：[1]山东省青岛疗养院

出　　处：《中国病案》2007年第12期16-18,共3页Chinese Medical Record

摘　　要：目的为配合卫生部“病历书写基本规范”和“山东省医疗护理文书书写规范”的实施,提高护理文书书写质量,保护护理人员自身利益,防范医患纠纷。方法随机抽取2003年1月-2004年12月出院病案300份,对照规范标准,检查发现护理文件存在缺陷,存在医患纠纷隐患。分析护理文件缺陷原因,加强为期6个月的防范医患纠纷的护理质量控制管理措施,再随机抽取2005年7月-2006年6月出院病案300份,进行检查对比。结果护理文件对照组与研究组比较,病历份数质量达标率由69.7%提高到80.7%（P〈0.05）,病历份数缺陷率由30.3%下降到19.3%（P〈0.05）,缺陷项次缺陷率由41%降到20.3%（P〈0.01）,其中体温单缺陷率由17.3%下降为13.7%,医嘱单由4%降为0.3%,护理记录由19.3%降为6.3%,（P〈0.05,P〈0.01）。结论提高护理人员综合素质和法律意识,关注护理文件书写重要性,严把护理病历书写质量关,是减少护理文件存在缺陷,提高护理文件书写质量,减少和防范医患纠纷的重要护理管理措施。Objective To carry out Basic Specification for Medical Records[200 2] issued by the Ministry of Public Health and Nursing Records Specification,i ssued by Shandong Province,to improve the quality of the nursing record,to pro tect the benefits of nursing staff and prevent disputes caused by nursing record s.Methods300medical records of discharged patients from January2003to December20 04have been selected randomly as samples to be checked,in line with the specifi cations,whether defects and potential problems existed.we analyze the reasons c ausing the defects and strengthen the measures to control nursing quality in pre venting disputes between medical workers and patients in6-month period.Then300me dical records of discharged patients from July2005to June2006were selected as co mparison samples.Results the comparison between the control group and the resear ch group shows that the percentage of medical records reaching the standard has i ncreased from69.7%to80.7%（P〈0.05%）and that of records with defects has decreas ed from30.3%to19.3%（P〈0.05）and the item defect rate decreased from41%to20.3%（ P〈0.01）,in which the defect rate of temperature sheets dropped from17.3%to13.7 %;that of doctor＇s advice records from4%to0.3%;that in nursing records from19.3 %to6.3%（P〈0.05,P〈0.01）.Conclusions the essential management measures to reduc e defects in nursing documents,to improve the qualiˉty of nursing documents an d reduce or avoid disputes between medical workers and patients include improvin g the quality of nursing staff and strengthˉening their law awareness,emphasiz ing the importance of nursing records and exercising strict control over the qua lity of nursing records writing.

关 键 词：护理文件 缺陷 医患纠纷 防范 

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