神经内科护理记录中的缺陷分析与对策

Analysis of the Defects in Neurological Nursing Records

目的了解目前神经内科护理记录中存在的缺陷,分析影响因素,提出护理对策,规范护理记录的书写。方法随机抽取神经内科病历200份,对体温单、医嘱单、护理记录单进行逐项检查,将存在的缺陷总结分析。结果查出缺陷主要有体温单上的漏记,空项,日期、页码错误,医嘱单代签名、漏签名问题,护理记录病情观察及描述重点不突出,记录不及时,与医疗病历不符,出入量记录不准确等。结论护理记录存在缺陷,应加强对护士法律知识、护理基础知识和专科知识的培训,并实行弹性排班,合理利用人力资源,实施质控与管理,以提高护理记录的质量。

[ Objective] To investigate the defects in neurological nursing records, analyze the influential factors, propose nursing strategies and standardize nursing records. [ Methods] 200 case files of neurological diseases were stochastically selected; detection was carried out on the temperature chart, doctors＇order and nursing records; analysis was made on the defects. [ Results] The main defects include temperature omitting, date and signature mistakes, wrong signature in doctors＇ advice, unnoticeable nursing records description, lack of prompt record and accordance with medical case history and inaccurate in and out amount records and so on. [ Conclusion] Defects do exist in the nursing records; trainings should be carried out on the legal knowledge, basic nursing knowl- edge and professional knowledge among the nurses ; the human resource should be utilized properly and quality supervision and management should be implemented in order to improve the quality of nursing records.