护理文件书写中常见问题原因分析与对策  

Analysis on the reasons and countermeasures of the common problems in nursing documentation

作　　者：胡红林[1] 刘梦[1] 任珍[1] 李惠聪[1] 

机构地区：[1]首都医科大学附属北京佑安医院护理部,北京100069

出　　处：《护理管理杂志》2008年第5期51-52,共2页Journal of Nursing Administration

摘　　要：目的提高护士书写护理文件的质量,减少因护理文件书写不当造成的医疗纠纷。方法对2007年终末护理病历抽查中发现的问题进行分析。结果护理文件书写缺陷原因主要与护理人员少、责任心及法律意识不强有关。结论提高护理人员法律意识,不断学习和加强培训,严格护理质量控制是护理文件书写质量的保证。Objective To improve the quality of documentation and reduce the medical disputes caused by unsuitable recoras of nursing uocumentauon. Method The problems founded in the terminal check of nursing documentation in 2007 were retrospectively analyzed. Result The defects in nursing documentation were mainly related to the deficiency of nursing staff,the weakness of sense of responsibility and legal awareness among nurses. Conclusion It is suggested to strengthen nurses＇ legal awareness,continuous learning and training,and strict nursing quality control to ensure the quality of nursing documentation.

关 键 词：护理文件 质量控制 护理管理 

分 类 号：R47[医药卫生—护理学]