200份护理记录内容回顾性调查

A Retrospective Investigation on the Contents of 200 Nursing Records

目的为落实《病历书写基本规范》(试行),提高护理记录书写水平。方法抽查2005年1月-6月出院病案200份,对护理记录进行回顾性调查。结果有121份护理记录不合格,占60．50%。主要问题：书写内容明显滞后；记录不能反映个性化病情；重点不突出；主诉、治疗记录多,实施护理活动记录少等。结论要严格按照规定、按照标准,制定相应的护理记录书写规范,指导临床护理记录工作。

Objective Implementing The Basic Norm of the Documentation of the Medical Record issued by the Public Health Department of Shandong Province and improving the quality of the nursing record. Method Selecting 200 nursing records from January to June in 2005, and making a retrospective investigation. Result 121 in 200 nursing records are unqualified, accounting for 60.5%. The key problems： the contents to fall behind obviously; the record cannot respond the changes of the conditions of the patients; the points are not standing out; the records of complaints and medical operations are much more than those of nursing activities. Conclusion The hospital should make certain policies according with the norm to guide the clinically nursing records.