护理文书书写中的缺陷及对策

The errors of nursing logs and the countermeasures

目的探讨护理文书书写中存在缺陷的对策,预防护理差错事故及纠纷的发生。方法采用重点患者每日查,在架病历每周查,出院病历全面查的方法,统计发现全年护理文书书写质量缺陷集中领域。结果通过统计发现,护理文书书写质量缺陷集中在:护理书写涂、刮现象;护理书写缺项;三测单与重护单生命体征不一致及病情观察记录不全、不使用医学术语等方面。结论加强医疗法律法规学习是提高护理文书书写质量的基础和前提;实施护理文书书写质量检查责任制,是提高护理文书书写质量的关键;制定和落实护理文书书写质量缺陷管理制度,是提高护理文书书写质量的保证。

Objective To investigate the countermeasureS to avoid errors in nursing logs in order to prevent from medical incidences in nursing. Methods Medical logs of the severe patients, common inpatients and discharged patients are reviewed once a day, a week and one time when discharging. Logs of the whole year we~ statistically analyzed. Results Revising and scraping casually, missing items, records of the general vital signs in accordance with the special ones, conditions of the patients recorded incompletely are the major errors of the nursing logs. Neither using medical terms is usually found. Conclusion Enhance the study o medical laws was the basis to improve the quality of nursing logs, carrying on nursing data quality inspection responsibility system, which was key to improve the quality of logs and induce the incidence of medical cases. Making and implementation of nursing data management system was the guarantee for nursing logs.