我院护理文书中的安全隐患分析与护理管理策略初探  

Study on safety hidden dangers of nursing documents of our hospital and nursing management strategies

作　　者：陈清[1] 陈伍[1] 梁晓红 CHEN Qing;CHEN Wu;LIANG Xiaohong(The People＇s Hospital of Suixi County,Suixi 524300,China)

机构地区：[1]广东省遂溪县人民医院,广东遂溪524300

出　　处：《中国医药科学》2018年第16期243-245,253,共4页China Medicine And Pharmacy

摘　　要：目的探讨我院护理文书中的安全隐患与护理管理策略。方法随机选取我院2016年11月~2017年11月收治的500例病患的病历,总结其中存在的安全隐患并对其进行原因分析,初步探讨护理管理模式。结果我院护理文书的书写存在一定的安全隐患,其中主要包括体温单、医嘱单、首次护理记录单、护理执行单和护理记录单。其主要是由于管理因素和护理人员因素而导致。结论通过对护理文书书写中存在的安全隐患分析,找出相应的原因并采取有效的措施可以加强文书的书写质量,促进护理科室的有效管理。Objective To explore the safety hidden dangers of nursing documents of our hospital and nursing management strategies. Methods Five hundred eases of patients admitted to our hospital from November 2016 to November 2017 were randomly selected, and the safety hidden dangers were summarized and the causes were analyzed, and the nursing management mode was preliminarily discussed. Results There were some security risks in the writing of nursing document in our hospital, which included temperature sheet, physician＇ s order sheet, first nursing record sheet , nursing executive order sheet and nursing record sheet. They were mainly due to the management factors and nursing staff factors. Conclusion Through analyzing the safety hidden dangers in the writing of nursing instruments, identifying the corresponding causes and taking effective measures, we can enhance the writing quality of the instruments and promote the effective management of nursing department.

关 键 词：护理文书 护理风险 安全隐患 护理管理策略 

分 类 号：R47[医药卫生—护理学]