护理记录书写存在问题的原因分析与对策

Aanlysis and countermeasures on the problems exitin the writing of nursing record

目的通过对笔者所在医院2007年1月至6月出院病历中护理记录书写存在的问题进行分析，提高护理记录书写的质量。方法根据质控要求，护理部每月抽查100份出院病历，对护理记录存在问题进行分析。结果问题原因是护理人员对护理记录书写的重要性缺乏认识，专科知识掌握不全面，对病情观察不仔细。结论通过对护理人员的法律意识、护理病历书写规范、专科知识的学习，有效地提高护理记录书写水平。

Objective To improve the writing quality of the nursing records by analyzing the problems exist in the writing out of hospital medical nursing records during January to June. Methods According to quality control requirements, the Nursing Department check 100 medical records monthly to analyze the problems exist in the nursing records. Results The reasons are due to nurses fail to recognize the importance of nursing medical records writing, lacking the full command of the specialized knowledge and care during the observation of illness. Conclusion To effectively enhance the level of nursing medical records by studying legal awareness, writing standard of nursing medical records and the specialized knowledge.