关于手术室护理记录若干问题的探讨

Discussion about the problems of nursing records in operating room

结合执行《病历书写基本规范(试行)》要求的体会和在填写手术室护理记录单的过程中遇到的一些问题进行初步探讨。其中包括有:手术名称记录、神志记录、皮肤情况记录、手术植入物记录、活检标本送检记录、器械及物品的记录、局部麻醉病人护理记录等,提出针对性对策与措施。同时对相关事项进行商榷,以期逐步完善、规范手术室护理记录单的格式及内容。

Combined with the experience of implementation of “the Protocol of Basic Criterion for Medical Records”,this article discussed the problems during the course of filling the form of in nursing records in operating room,which including records of operations’ name,patients’ consciousness,status of skin,records of implant substance,specimen by biopsy,appliance and instruments,nursing records of patients who were under local anesthesia and so on.Also,the author put forward and discussed some countermeasures in order to perfect and standardize the form and content of nursing records in operating room gradually. Author’s address:Operating Room,Xiangya Hospital of Central South University,Changsha 410008,China