护士“通知”与“发现”义务的法律和现实意义

Consideration on Noticing and Finding Duty of Nurses

目的探讨护士通知义务和医嘱违规发现与报告义务的证据保存方法。方法以护理记录和说明书等书面材料作为标准,进行方法分析。结果护理记录、药品说明书的禁忌证和本科室常规操作的禁忌证可以帮助护士举证。结论严格、详细记载,并向医生报告患者病情危急情况的护理记录,帮助发现违规医嘱的记载及禁忌证的药品说明书,规定本科室常规操作禁忌证的操作流程,对护士履行通知与发现义务,避免医疗纠纷和护患纠纷的发生具有重要意义。

Objective To discuss the preserving methods of evidence of noticing duty and finding and reporting duty of irregularities of doctors' advices for nurses.Methods The nursing records and the medical leaflet were taken as standards for method analysis.Results The nursing records,the contra-indications of medical leaflet and the contra-indications of the regular operation could help nurses adduce evidence.Conclusion To fulfill the finding and noticing duty and avoid medical disputes and nurse-patient disputes,a series of procedures were performed including strict and detailed records and reports of patients' critical conditions,assistance in finding records of irregularities of doctors' advices and the contra-indications of medical leaflet,and regulation of operational procedure on regular operational contra-indications.