基层医院护理记录缺陷分析与安全管理

Analyze the Shortage of Nursing Record and Safety Management in basic Hospital

目的::探讨基层医院护理记录质量控制缺陷管理方法,提高护理记录质量,保护护士自身利益,减少医疗纠纷。方法:随机抽查2004年和2005年7至12月份护理记录分析,提出管理对策,对护士进行法律知识教育,专业知识以及护理记录相关培训等。结果:通过医院管理年的护理工作规范化管理。2004年7至12月和2005年7至12月同期护理记录质量明显增高。结论:完善各级质量管理,规范基层医院护理记录,对促进护理记录质量的提高起到至关重要的作用。

Objective： Exploring the management and shortages of nursing record in the basic hospital in order to raise the quality of nursing record, protect the profits of nurses and reduce the medical treatment disputes. Method：Put forward the management conturplan, open the exhibition of the law knowledge education, professional knowledge and training of nursing record to the nurse through carrying out randomly and analyzing the nursing record from July to December in 2004 and 2005. Result： The quality of nursing record from July to December in 2004 was higher than those in 2005. through the nursing management in year of hosnital management. Conclusion.Perfect all of the quality management and norming the nursing record of basic hospital are important to raise the quality of the nursing record.