归档护理记录存在主要问题之症结及应对

目的通过系统分析归档护理记录,找出存在主要问题的共性,针对症结成因提出应对方法。方法随机抽取内一科、外科、儿科、综合科四病区归档护理记录400份,将所存在问题合并归类,然后就问题共性进行分析,并提出有效应对方法。结果在400份护理记录中发现问题355个,其中违反护理记录书写规范的问题有298个,占存在问题的83.9%。结论严格护理记录书写规范是保证护理记录真实有效的必要手段。

Objective To analyze systematically those problems in nursing records in our hospital and find out their commonness, and put forward methods of resolution. Methods Four hundred files from four departments were randomly studied, the common problems were summarized. Finally the strategy was put forward. Results Three hundred and fifty-five defects were found, among which there were two hundred ninety-eight cases against nursing record rules. It counted for 83.9%. Conclusions The criterion of recording nursing document must strictly be carried out among the nurses in the hospital.