护理文书中潜在的法律责任问题的分析  

Analysis of latent law responsibility in nursing records

作　　者：陈亚沙[1] 

机构地区：[1]宁波市第一医院护理部,浙江宁波315010

出　　处：《南方护理学报》2003年第5期75-76,共2页Nanfang Journal of Nursing

摘　　要：笔者分析护理文书潜在的法律责任问题。阐述常见的典型的潜在的法律责任问题有:体温单的入院日期或时间写错,医嘱单上误把mg写成g,重病观察记录单上血压漏记,护理病情记录单上的记录与医生记录不符或记录不全。认为护理文书的书写和管理是履行法律义务,护理文书的使用和质量存在法律意识,加强质控管理是保证护理文书质量的关键。The author in this paper analyzed latent law responsibility in nursing records,stating common typical latent law responsibility in nursing records included:wrong records of admission date and time in temperature report;mistaking mg for g in medical order;no accordance between the contents in nursing report or incomplete nursing records.The author argued that it is implementation of law responsibility for nurses to write and management nursing documents.The utility and quality of nursing reports involve law consciousness.The reinforcement of quality control is key in ensuing the quality of nursing reports.

关 键 词：护理文书 法律责任 体温单 医嘱单 重病观察记录单 护理病情记录单 

分 类 号：R471[医药卫生—护理学]