护理文书质量缺陷的调查与分析  

Investigation and analysis of quality defects in nursing documents

作　　者：谭秋荣 TAN Qiu-rong

机构地区：[1]驻马店市中医院病案室,驻马店市463000

出　　处：《护理实践与研究》2018年第20期12-14,共3页Nursing Practice and Research

摘　　要：目的调查护理文书质量缺陷情况,并进行现状及原因分析,为护理文书质量提升提供理论依据。方法本次现状调查资料为某医院2017年1月至2018年1月300份护理文书,以中华人民共和国国家卫生和计划生育委员会《病历书写基本规范(试行)》为标准,调查300份护理文书护理记录单、医嘱执行单、特别护理记录单、体温单以及外科术中护理记录单护理文书质量评分;调查所有护理文书书写缺陷次数,分析各项书写缺陷比例情况,并对缺陷文书相关护理人员进行原因调查。结果 300份护理文书中护理记录单评分(22. 12±3. 23)分,医嘱执行单(19. 33±3. 43)分,特别护理记录单(21. 23±4. 34)分,体温单(10. 56±2. 12)分,外科术中护理记录单(12. 32±1. 21)分; 300份护理文书共计245份发生书写缺陷,缺陷率81. 67%;出现护理文书书写缺陷共计1103次,其中前3位为入院2 h生活能力(Barthel指数)评价,护理文书整洁、规范、无破损、无错字,对护理措施、计划进行效果评价;调查245名责任护士显示护理文书书写缺陷原因中前3位为护理工作量大、未进行规范化培训、交接班沟通不详细。结论某医院调查护理文书质量存在着较多缺陷,护理人员主要反映护理工作量大、未进行规范化培训等情况,有待进一步提高护理文书书写质量,规避医疗纠纷风险。Objective To provide theoretical basis for improving the quality of nursing documents,the quality defects of nursing documents were investigated,and the current situation and causes therefrom were analyzed.Methods To investigated the nursing document quality scores in nursing sheet,medical advice execution lists,special care record sheet,temperature chart,and the surgical nursing sheet;to investigated the number of writing defects in all nursing documents,analyzed the proportion of writing defects,and carried on causes investigation to nursing staff concerned with the defect documents,300 nursing document dated from January 2017 to January 2018 of a certain hospital were included,and observed in accordance with National Health and Family Planning commission of PRC's"Basic Specifications for Medical Record Writing(Trial)".Results Among those 300 nursing documents,the nursing sheet scores was(22.12±3.23)points,medical advice execution list was(19.33±3.43)points,special care record sheet was(21.23±4.34)points,temperature chart was(10.56±2.12)points,and the surgical nursing sheet was(12.32±1.21)points.Among those 300 nursing documents,245 cases detected writing defects,with the defect rate of 81.67%.A total of 1103 cases of writing defects in the nursing documents occurred,of which the top 3 were,assessment of inpatient living ability(Barthel index)for 2 hours,nursing documents of clear,standard and intact,and evaluation of effect of nursing measures and plans.Among the 245 responsible nurses surveyed,the first three reasons for writing defects were heavy workload,no standardized training,and insufficient communication during the shifting of duty.Conclusion there were many defects in the quality of nursing documents investigated in a certain hospital.Nursing staff mainly complained about the heavy nursing workload,lack of standardized training and so on.The quality of nursing documents should be further improved in order to avoid the risk of medical disputes.

关 键 词：护理文书质量 缺陷 原因调查 

分 类 号：R47[医药卫生—护理学]