基层医院护理记录单存在的纠纷隐患分析及对策

Basic unit hospital care label existence dispute hidden danger analysis and countermeasure

目的分析护理记录单纠纷隐患产生原因,并探讨相应防范对策。方法用统一的质量标准检查952份护理记录单,对存在的缺陷用表格形式按百分比分类列出。结果通过原因分析,认为护理记录单存在的纠纷隐患与字迹潦草、涂改刮痕,记录简单、陈述不清,记录不全面、缺乏连续性,医护记录不一致,未使用医学术语,用符号代替文字,签名不规范,重抄等因素有关。结论加强护士法律知识、业务知识的学习,加强医护交流,通过多环节质量监控,应用奖惩机制,合理使用人力资源等防范措施来应对护理记录单存在的问题,从而提高护理质量,避免医疗纠纷的发生。

Objective The analysis nursing label dispute hidden danger has the reason, and discusses the corresponding guard countermeasure. Methods Inspects 952 nursing labels with the unification quality specification, lacks to the existence hidden lists with the tabular form according to the percentage classification. Results Through the reason analysis, thought that the nursing label existence the dispute hidden danger and the sloppy handwriting, the modification scratch, the record is simple, the statement is unclear, records, the deficient continuity not comprehensively, the medical treatment and nursing record is inconsistent, has not used the medicine terminology, replaces the writing with the mark, signs not standard, reproduces and so on factors to concern. Conclusion Strengthens nurse the legal knowledge, the professional knowledge study, strengthens the medical treatment and nursing exchange, through the multi-link quality monitoring, the application rewards and punishment mechanism, uses measures and so on human resources to deal with the nursing label existence reasonably the question, thus the enhancement nursing quality, avoids the medical dispute＇ s occurrence.