社区护士护理文件书写相关知识管理现状调查  

A survey of the relating knowledge on nursing documentation of community nurses

作　　者：杨爱军 万巧琴[2] 

机构地区：[1]北京市中关村医院,100190 [2]北京大学护理学院

出　　处：《中国护理管理》2010年第6期41-43,共3页Chinese Nursing Management

摘　　要：目的:了解社区护理人员在家庭护理过程中护理文件书写现状。方法:采用自设问卷,对16家社区卫生服务机构94名社区护理人员进行问卷调查。结果:94例社区护士中44例(46.8%)不熟悉病历书写规范;70例(74.5%)认为病人有权复印护理记录单、医疗病历、病程记录等资料;74例(78.1%)不了解因抢救急危病人未能及时书写护理记录,应在6小时内核实后据实补记;89例(94.7%)认为试用期人员经医疗机构审核可以独立书写护理记录;15例(16.0%)不能够在完成家庭护理后即刻完成护理记录;49例(52.1%)护士在家庭护理的病人无签字能力时,经病人口头授权会让保姆代签。结论:社区护理人员医疗文书书写相关知识掌握不足,应针对家庭护理过程中如何完善护理记录的知识进行培训。Objective： To investigate the status of nursing documentation of community nurses during the process of home care. Methods： With a self-designed questionnaire, totally 94 community nurses from 16 community health services facilities were recruited to participate this survey. Resuks： Among the 94 cases of community nurses, 44 cases （46.8%） were not familiar with the norms of case records; 70 cases （74.5%） thought that patients had the right of coping nursing records, medical records, progress notes and so on; 74 cases （78.1%） didn＇t know that the nursing documentation should be finished within 6 hours after emergency treatment; 89 cases （94.7%） thought that nurses could write the documentation independently when they passed the auditing by medical organizations in the trial employment period; 15 cases 06.0%） couldn＇t finish nursing documentation immediately after providing home care services; 49 cases （52.1%） would allow the bonnes to sign on the behalf of the patients if the patients had no ability to sign and made an oral authorization to their bonnes. Conclusion： The knowledge of nursing documentation were not enough for community nurses, they should receive some training programs about how to write nursing documentation of home care.

关 键 词：社区护理人员 家庭护理 文件书写 

分 类 号：R47[医药卫生—护理学]