体温单存在的法律性问题及应对举措  

Legal Problems in the Temperature Sheet and the Countermeasures

作　　者：刘玉琳 黄功兰 

机构地区：[1]重庆市万州区人民医院护理部,重庆市404000

出　　处：《中国病案》2010年第4期38-40,共3页Chinese Medical Record

摘　　要：目的了解体温单的描、记情况,认识体温单在病案质量及医疗纠纷举证责任的重要作用。方法依据《重庆市护理文件书写规范》标准,检查2008年10月-2009年3月的1200份病案,找出存在的法律性问题,并提出改进措施。结果体温单上存在的法律性问题比较突出,体温单上缺陷项为15%-36%。结论增强法律意识、证据意识和质量意识,正确描、记体温单上的项目,可以提高病案质量及诉讼时举证有力有据。Objective To describe the drawing of temperature sheet and recognize its important role in the quality of medical records and evidence adducing in the medical disputes.Methods According to the standard of ＂Nursing Records Writing Norms in Chongqing＂,1200 records archived from October,2008 to March,2009 were inspected,to identify the existing legal problems and propose measures for improvement.Results Legal problems existing in the temperature sheet were prominent,among which defective items accounted for 15%-36% of the total items.Conclusion Enhancing the legal awareness,evidence consciousness and sense of quality,and correctly drawing the temperature sheet,can improve the quality of medical records and provide strong evidence in the lawsuit.

关 键 词：体温单 法律隐患 应对措施 

分 类 号：R47[医药卫生—护理学] R-051[医药卫生—临床医学]