护理文书中相关法律风险的探讨及对策

The Legal Risks and Countermeasures of Nursing Documents

目的通过对护理文书质量检查的结果进行分析,使护理文书书写质量得到提高,以降低法律风险,减少纠纷隐患。方法每月随机抽查病例200份,对发现的质量问题,在每月的护士长例会上进行反馈。结果护理文书书写质量较《医疗事故处理条例》逐月大幅度提高,但仍然存在字迹不清、涂改、漏项、记录内容欠规范等缺陷。结论注重护理质量控制,加强护理人员法律意识和业务技能培训,建立健全病历书写管理制度,是提高护理文书书写质量的重要措施。

The purpose of the paper is to improve nursing documents writing quality in nursing quality control through analyzing nursing documents quality check reports. Specifically, quality control group of nursing department check the quality of nursing eases randomly. The feedback will be given in the meeting of head nurses every month and awarded prizes or punished respectively. After practiced a period of time, the writing quality is improved significantly month by month compared to the time before Regulations on Handling Medical Accidents was implemented. However, some defects such as illegible writing, altering, items missing, nonstandard writing are still in existence. Therefore, improve nursing quality control, strengthen legal awareness and professional skills training, develop corresponding rewards and punishments system, and improve medical records writing management system are important measures for improving nursing documents writing quality.