精神科低年资护士护理记录书写缺陷分析及对策  

Analysis on Nurse Record Flaw Written by Psychiatry Low Period of Service Nurses and the Countermeasure

作　　者：魏玉莲[1] 魏玉涛[2] 李云贤[1] 刘立英[1] 陈海英[1] 

机构地区：[1]河北省第六人民医院 [2]保定市第一人民医院

出　　处：《中国健康心理学杂志》2011年第7期813-814,共2页China Journal of Health Psychology

摘　　要：目的探讨精神科低年资护士护理记录中存在的书写缺陷,分析其影响因素并提出对策方法,提高低年资护士书写精神科护理记录的质量,避免医疗纠纷。方法随机抽取精神科护理记录200份,对记录中出现的问题及记录的护士进行分析。结果精神科低年资护士书写护理记录出现的问题与较高年资护士相比较,经2χ检验有显著性差异(P<0.05)。填写项目不全、漏项、涂改(χ2=4.034,P=0.045),护理内容重点不明确,不能体现专业特点(2χ=5.973,P=0.015),记录内容缺乏连续性、完整性(2χ=5.079,P=0.024),文字书写基本功欠缺(χ2=5.334,P=0.021),医护记录不一致(χ2=4.318,P=0.038),记录不规范(2χ=5.637,P=0.0.018),记录不及时(χ2=4.134,P=0.042),其他(2χ=4.66,P=0.031)。结论应加强培养低年资护士的法律意识,提高其业务能力,健全护理记录质量控制体系,才能保证低年资护士书写出高质量的护理记录,确保护理安全。Objective To discuss the nurse record flaw written by psychiatry low period of service nurses,analyze its influencing factors and propose the countermeasure,enhance the record quality written by low period of service nurses,avoid the medical dispute.Methods A total of 200 cases of nurse records were randomly drawn,the problems and record nurses were analyzed.Results The nurse record flaws written by psychiatry low period of service nurses showed significant differences compared with those written by the high period of service nurses by chi-square test χ2（P0.05）.The filling project was not entire,leaked the item,and the modification（χ2=4.034,P=0.045）;the nursing content was not with emphasis explicit,the specialized characteristic could not be manifested（χ2=5.973,P=0.015）;the record content lacked continuity and integrity（χ2=5.079,P=0.024）;the writing was short of basic skills（χ2=5.334,P=0.021）;medical treatment and nursing record was inconsistent（χ2=4.318,P=0.038）;records were not standard（χ2=5.637,P=0.0.018）;records were not prompt（χ2=4.134,P=0.042）;others（χ2=4.66,P=0.031）.Conclusion The legal consciousnes should be strengthen to the low period of service nurses,their professional qualification should be improved,nursing record quality control system should be improved,to ensure low period of nurses＇ nursing records quality and nursing safety.

关 键 词：精神科 低年资护士 护理记录 缺陷分析 对策 

分 类 号：R192.6[医药卫生—卫生事业管理]