急诊抢救护理记录缺陷分析  

Analysis on defects of Emergency Rescue Nursing Records

作　　者：姚桂芬 叶先智 赵晶 Yao Guifen;Ye Xianzhi;Zhao Jing(Wuhan Third Hospital(The Affiliated Hospital of Wuhan University),Wuhan 430074,Hubei Province,China)

机构地区：[1]武汉市第三医院(武汉大学附属同仁医院)

出　　处：《中国病案》2019年第12期14-16,共3页Chinese Medical Record

摘　　要：目的探讨急诊抢救护理记录存在的缺陷,提出改进急诊抢救护理记录书写质量的举措,提高护理文书书写质量。方法采取分层等比随机抽取2019年1月-2019年6月急诊抢救室抢救护理记录1000份,组成检查小组按照《医疗机构病历管理规定》和《护理记录质控评分表》分6个大类进行质控。质控结果采用描述性统计方法进行分析。结果 1000份急诊抢救护理记录中,497份存在缺陷,比例为49.7%。总缺陷频次为2789频次,其中病情记录881频次,占31.59%;书写记录878频次,占31.48%;药品记录369频次,占13.23%;签名记录336频次,占12.05%;医患沟通记录179频次,占6.42%;眉栏记录146频次,占5.23%。结论加强急诊护士职业道德、业务素质、法律法规培训,完善抢救护理记录书写管理制度,加强抢救护理记录质控,加强医护沟通,持续改进抢救护理记录书写质量。Objective To discuss the defects existing in the emergency rescue nursing records, and puts forward some measures for improving the writing quality of the emergency rescue nursing records and improving the writing quality of the nursing documents.Methods From January 2019 to June 2019, 1000 nursing records were randomly selected from the emergency room. According to the regulations of medical records management and the quality control score table of nursing records, quality control was carried out in six categories. The results of quality control were analyzed by descriptive statistical method.Results Of the 1000 emergency nursing records, 497(49.7%) were defective. The total frequency of defects was 2789, of which the frequency of disease record was 881, accounting for 31.59%, the frequency of writing record was 878, accounting for 31.48%, the frequency of drug record was 369, accounting for 13.23%, the frequency of signature record was336, accounting for 12.05%, 179 times(6.42%) of doctor-patient communication and 146(5.23%) of eyebrow column records.Conclusion We should strengthen the training of professional ethics, professional quality, laws and regulations of emergency nurses, perfect the management system of emergency nursing record writing, strengthen the quality control of rescue nursing record, strengthen the communication between medical and nursing, and continuously improve the writing quality of rescue nursing record.

关 键 词：急诊护理 抢救记录 书写缺陷 对策 

分 类 号：R47[医药卫生—护理学]