死亡病案中护理记录潜在的法律问题与对策

The Potential Legislate Problems in the Nursing Records of the Deaths and the Countermeasures

目的提高护理记录质量,保证其法律效用。方法从病案室中抽取死亡病案40份,由质控员进行终末质量评价。结果提示在死亡病案护理记录中发现潜在的法律性问题,如配合抢救过程记录简单、无抢救措施、出入量计算错误、缺乏整体护理的理念、涂改、补记、重抄护理记录等。结论加强对护士的法律知识、病历书写知识、相关理论及专业知识的学习和考核,加强病历质量管理,增员、减负,提高护士的法律意识和护理书写质量,推动护理事业不断前进。

Objective To improve the quality of nursing records and ensure their effectiveness. Method Taking out 40 medical records, the professional who is responsible for quality control evaluates them terminally. Result The findings show that there are potential legislate problems in the nursing records in the records of deaths, for example： too simple records about the process of the emergency treatments, without noting the measures, mistakes in calculating the input and output, being lack of the philosophy of nursing, being altered, making up the records, or re-writing the records. Conclusion We should strengthen the education and examination of law, documentation of records, and related theory and knowledge, and the management of quality assurance of nursing records. Furthermore, we should increase the nursing professionals so as to reduce the daily work of the nurses.