362份危重病患者护理记录缺陷分析及干预的研究

The analysis on deficiencies of 362 nursing records of critical patients and countermeasures

目的:探讨规范危重病患者护理记录书写应遵循的原则和规范,提高护理病历质量。方法:对362份危重病患者护理记录单存在的缺陷进行统计分析。结果:确定了危重病患者护理记录单的缺陷原因,提出相应的干预措施,保证护理质量和病案的完整性。结论:要加强质量监督,确保护理文书的规范化,以防护理纠纷的发生,便于医院内病案实行统一规范化。

Objective： To explore the standard of nursing records of critical patients. Methods： 362 nursing records of critical patients have been investigated. Results： the reasons for deficiencies have been found and countermeasures have been proposed. Conclusion： The quality control of nursing records of critical patients should be strengthen in order to standardize nursing record and prevent nursing dispute.