内科护理记录存在的问题及改进方法  

Problems and improving methods of medical nursing records

作　　者：杨英[1] Yang Ying(Academy of Traditional Chinese Medicine Hospital of Weng'an county,Guizhou Province 550400)

机构地区：[1]贵州省瓮安县中医院,550400

出　　处：《中国社区医师》2017年第1期166-166,168,共2页Chinese Community Doctors

摘　　要：目的:探究内科护理记录中存在的问题以及具体的改进方法。方法:选取患者的内科护理记录40例,随机平分为两组,对所有护理记录的书写规范性进行检查、分类和统计。结果:在内科护理工作中,护理记录中常见的问题主要有护理记录不全面、医嘱内容与实际护理记录不符合、护理记录前后有矛盾等。观察组内科护理记录存在的问题明显少于对照组,组间差异具有统计学意义(P<0.05)。结论:在内科护理记录中,存在很多安全隐患,对此,对问题进行仔细分析,然后采取相应的解决对策,这样才能够有效保证护理记录的准确性和真实性,提高护理记录参考价值。Objective:To discuss the problems in medical nursing records and the specific improvement methods.Methods:40cases of medical nursing records were selected.They were randomly divided into the two groups on average.All written records ofnursing records were checked,classified and counted.Results:In the medical care work,the nursing records of the main problemsare that the nursing record was not comprehensive,the contents of the doctors'advice was not consistent with the actual nursingrecords,before and after nursing records exist contradictions and so on.The medical care records of the problem in the observationgroup was significantly less than the control group,and the difference between groups was statistically significant(P<0.05).Conclusion:In medical nursing records,there are many security risks.In this regard,the problem should be carefully analyzed andthen take corresponding measures to solve,so that it can effectively guarantee the accuracy and authenticity of nursing records,improve the value of nursing records.

关 键 词：内科 护理 方法 

分 类 号：R473.5[医药卫生—护理学]