危重病人护理记录中的缺陷分析与对策

An analysis of the limitation existed in the nursing records of gravely ill patients and its countermeasures

目的:了解危重病人护理记录中的缺陷问题,分析其影响因素,并提出护理对策,以提高护理记录质量,使其更加符合《医疗事故处理条例》等对护理记录书写的规范和要求,减少医疗纠纷。方法:设计调查表,对随机抽取的150份危重病人护理记录单进行逐项检查,将其主要缺陷进行统计分析。结果:查出缺陷36处,包括出入量记录、用药记录、病情观察及描述缺陷、护理计划实施及效果评价、护理计划的制订与修改等缺陷。对策:加强对护士法律知识及专业知识的培训;制定危重病人护理程序及护理记录单的质控标准,针对缺陷提出改进措施;加大检查力度;弹性排班,合理用人。

Objectives： To find out the existed in the nursing records of gravely ill patients and analyze the related factors. To bring forward the correskponding nursing measures to impure the quality of nursing records to make them consistent with the Malpracticehandling Regulations better and reduce the medical disputes. Methods： One hundred and fifty gravely ill patient musing record sheets was randomly checked and the main limitation was analyzed. Results： Thirty six pieces of limitation were found, including the liquid amount of discharge ＆ intake, medication, patient station observation ＆ the implantation of nursing plan and the outcome evaluation, the constitution and amending of nursing ptan. Countermeasures： Strengthen the nurses＇knowledge about law and nursing specialty. Develop the nursing procedure of gravely ill patient and the quality control criteria of nursing record sheet and bring forward the corresponding measures to control the limitation. Strengthen the quality . Arrange the job shifts flexibly and use the manpower reasonably.