护理病历书写水平的相关因素研究

Study on factors related with quality of nursing records

目的探讨影响护理病历书写水平的因素。方法对北京市4所医院的100名临床一线内外科护理人员进行问卷调查,内容包括对书写护理病历的认识、态度等。结果护理人员对加强法律知识和诊疗常规学习及积极书写护理记录的态度总体得分均比较低,年龄大、职称高、教育程度低的护理人员对护理病历的认识低于其他组（P〈0.05）,年龄、职称对书写护理病历的重要性认识呈负相关,教育程度与护理病历书写的认识呈正相关;教育程度和职称是举证倒置、规范护理行为对护理病历书写水平影响的主要因素。结论护理人员应该重视护理病历书写的意义,特别是年龄大、职称高的护理人员,提示管理者应该对不同年龄、不同职称的护理人员开展持续地、系统地、有计划地学习和研讨,而不是有所侧重。

Objective To explore the factors that affected the quality of nursing record.Methods 100 clinical nurses in 4 hospitals in Beijing were investigated through questionnaire.The content of the questionnaire included their cognition and attitude to nursing records.ANOVA was used for comparison between groups;linear correlation and multi-variable regression were used for the analysis of the factors.Results The scores of the nurse＇s cognition on law knowledge and diagnosis and treatment routine study,and their attitude to nursing records were relatively low on the whole.The cognition levels of the nurse with old age,higher professional position and less educated were lower than other groups（P〈0.05）.Correlation analysis of the factors indicated that the nurse＇s age and professional position had negative correlation with their cognition on the importance of nursing record;and education had positive correlation with cognition on the nursing record.Multi-variable regression indicated that education and professional position were the major factors through which inverse burden of proof and standard nursing activities affected nursing records.Conclusions The nurse,especially those with old age and high professional position,should pay attention to nursing records.Nursing administrator should offer the chance of persistent and systemic and programmed study and discussion for the nurse with different ages and different professional positions.