急诊危重患者护理记录中的安全问题及对策  

Safety problems and Countermeasures in nursing records of critically ill patients in emergency department

作　　者：王金玲[1] 高玉红[2] Wang Jinling;Gao Yuhong(Department of Emergency Room,Armed Police Corps Hospital of Beijing 100027;The First Retired Cadres of Tianjin,General Logistics Department 300171)

机构地区：[1]武警北京总队医院急诊科,100027 [2]总后天津第一干休所,300171

出　　处：《中国社区医师》2017年第29期163-164,共2页Chinese Community Doctors

摘　　要：目的:提高危重患者护理文书书写质量,减少急诊护理记录相关纠纷的发生。方法:对急诊216份《危重患者护理记录单》进行抽查。对检查中存在的问题进行分析,对急诊护理人员实施规范化培训,严格落实相关奖惩制度。结果:护理人员能够深刻认识到急诊危重患者护理文书的重要性、文书不合格的危害性以及写好护理记录的必要性。结论:通过加强急诊护理文书质量的管理,增强了护理人员的法律意识、强化了工作责任心、提高了护理文书书写能力,有效减少了相关问题的发生。Objective:To improve the quality of nursing document writing in critically ill patients,reduce emergency nursing and torecord related disputes.Methods:Random examination of emergency nursing records of216critical patients was conducted.Theexisting problems in the examination should be analyzed and standardized training for emergency nurses should be carried out,andrelevant rewards and punishments should be strictly implemented.Results:Nursing staff are deeply aware of the importance ofemergency care documents,the dangers of nonconformities,and the need to write.Conclusion:By strengthening the management ofthe quality of emergency nursing documents,the legal awareness of nursing staff has been strengthened,the sense of responsibilityhas been strengthened,and the writing ability of nursing documents has been improved,and the related problems have beeneffectively reduced.

关 键 词：急诊 危重患者 护理文书 安全 对策 

分 类 号：R47[医药卫生—护理学]