精神科护理记录书写缺陷分析及对策

Analysis of nursing record defects in psychiatric departments and countermeasures

目的 提高护理记录书写质量,防范医疗纠纷的发生。方法 2003年10月在医院组织学习了《医疗事故处理条例》、《上海市精神卫生 条例》、《病历书写基本规范(试行)》及相关法律法规,每月随机抽查50%的住院及出院病历,半年共抽查病历1063份,对护理记录中涉及法 律问题的书写缺陷进行分析,提出防范对策,结果 护理记录书写质量明显提高,合格率从70%提高到96%。结论 通过培训、考核、评价和 有效的改进措施,可较快地提高护理记录质量,防范医疗纠纷的发生。

Objective To improve the writing quality of nursing records and to prevent the occurrences of medical treatment disputes.Methods The “Malpractice Settling Regulations”,Mental Health Regulations in Shanghai City,Basic Standards of Writing Medical Records(try out) and other related laws and regulations were studied by hospital nurse staff in October 2003. Every month fifty percent of the medical records of inpatients and out-patients were randomly checked. The total of 1 063 records were checked in six months.The writing defects of the nursing records concerning legal problems were analyzed.Preventive countermeasures were formulated.Results The writing quality of nursing records has been improved and the qualified rate has been raised from 70% up to 96%.Conclusion Strict test and evaluation after studying and training can improve the writing quality of nursing records so as to prevent medical disputes.