急诊护理记录单的设计与应用

The design and application of emergency nursing records sheet

目的完善急诊护理记录,避免医疗纠纷。方法将原有的急诊护理记录项目表格化,重视院前抢救记录和各种时间记录。落实不同急救人员(院前、急诊室、病房)交接时的签名制度。结果规范了院前急救、急诊抢救的护理流程,提高了病人满意率,降低了医疗纠纷的发生。结论急诊护理记录单实用,有效地促进了急诊护理质量的提高。

Objective To improve the emergency nursing records and to avoid medical disputes. Method The former items of emergency nursing records were formulated into a sheet,which emphasized on the records of first aid before hospitalization and the records of time. At the same time,the rules and regulations of signing were strictly implemented during the delivery before hospitalization, in emergency room and ward. Result This practice standardized the nursing flow of first aid before hospitalization and in emergency room, increased patients＇ satisfaction and reduced medical disputes. Conclusion The emergency nursing records sheet was proved to be practical and effective, which improved the quality of emergency nursing.