护理病案质量与护士工作投入状态关系的分析  

Analysis of the Relationship between the Quality of Nursing Records and the Work State of Nurses

作　　者：卢燕姿 陈蓓 陈奋琼 马湘燕 

机构地区：[1]广东省汕头市龙湖区人民医院病案室,汕头市515041

出　　处：《中国病案》2013年第4期11-12,共2页Chinese Medical Record

摘　　要：目的为提高护理病案质量,对护理病案常见缺陷进行统计分析,指出病案质量与护士工作状态的相互关系及探讨相应对策。方法根据《病历书写基本规范》和《护理病历评分标准》对1976份出院病案终末质检,对存在的主要缺陷与临床护理人员进行交流探讨和分析。结果护理病案存在各种缺陷,缺项、漏项为最常见,占所有缺陷的45.4%,主要原因与工作状态密切相关。结论要保持护士身心健康,提倡爱岗敬业,认识护理病案的重要性,克服职业倦怠,提高工作投入状态。Objective To improve the quality of nursing records by making statistical analysis on the common defects in nursing records, then point out the relationship between medical records quality and the working state of nurses, and explore relevant counter- measures. Method According to the ＂Medical Records Writing Rules＂ and ＂Scoring Standard of Nurses Records＂, we conducted ter- minal quality inspection to 1976 discharged nursing records as well as discussed and analyzed the mainly existing defects with clinical nurses. Result There are various defects in the nursing medical records, and the most common are the absence and missing of items, the rate is 45.4%, the main reason is closely related to the working state. Conclusion We should maintain the physical and mental health of nurses, advocate dedication, realize the importance of nursing records, overcome the occupation burnout and improve work engagement state.

关 键 词：护理病案质量 书写缺陷 法律意识 身心健康 工作状态 

分 类 号：R47[医药卫生—护理学]