whipple术后腹腔出血护理病案存在问题及对策  

Problems and Countermeasures of Nursing Records of Patients with Abdominal Bleeding after Whipple Operation

作　　者：高艳平[1] 王苑[1] Gao Yanping;Wang Yuan(Hepatobiliary, Pancreatic and Splenic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China)

机构地区：[1]首都医科大学附属北京朝阳医院肝胆胰脾外科,北京市100020

出　　处：《中国病案》2017年第12期27-30,共4页Chinese Medical Record

摘　　要：目的分析根治性胰十二指肠切除(whipple)术后腹腔出血患者的护理病历书写中存在的主要问题,以提高护理病案的质量。方法选取某院2014年1月1日-2017年6月30日行whipple手术术后并发腹腔出血患者的护理病案共33份进行回顾性分析。结果33份护理病案中有13份存在问题,占39.4%,主要问题为病历书写缺乏规范性,未采用医学术语3份,占23.1%;对病情观察记录不全、重点不突出4份,占30.8%;不能体现患者病情变化过程2份,占15.4%;护理记录前后不一致4份,占30.8%。结论通过加强专业知识及病历书写的培训,制作标准的护理病历模版,加强法律知识学习,成立质控小组并规范检查制度,建立质控考核制度,可减少护理病案问题的发生,有效提高书写质量。Objective To analyze the main problems existing in the nursing records of patients with abdominal bleeding after radical pancreaticoduodenectomy（Whipple）, so as to improve the quality of nursing records.Methods A total of 33 nursing records of patients with abdominal bleeding after Whipple operation in our hospital from January 1, 2014 to June 30, 2017 were retrospectively analyzed. Results There were 13 problems in 33 nursing records, accounting for 39.4%. The main problem is the lack of standardization of medical record writing.Medical terminology is not used, 3 copies, accounting for 23.1%; the observation record is not complete, the focus is not prominent, 4 copies, accounting for 30.8%; Can not reflect the patient＇s condition change process, 2 copies,accounting for 15.4%; Inconsistent nursing records, 4 copies, accounting for 30.8%. Conclusion Through the strengthening of professional knowledge and training of medical records, nursing records template to make the standard, strengthen the legal knowledge, the establishment of quality control team and standardize the inspection system, the establishment of quality control system, can reduce the occurrence of nursing records, improve the quality of writing.

关 键 词：护理病案 质量 根治性胰十二指肠切除术 出血 

分 类 号：R197.323[医药卫生—卫生事业管理]