中医护理记录单书写缺陷及对策

Defects and countermeasures of nursing records

护理记录单是病历资料的重要组成部分,是护士对护理对象所进行的一系列活动的真实反映,也是医疗纠纷发生时的直接证据。护理记录单具有"四性",即客规真实性、连续完整性、准确及时性、规范统一性。如果护理记录失去了真实性和完整性,一旦出现医疗纠纷,势必造成举证困难甚至举证失败,给医院和个人造成不必要的损失。如何提高护理记录单的书写质量是护理管理者面临的重要课题。为此,护理部每日派专门负责护理文书质量考核成员对护理单进行检查,针对存在的问题采取相应对策,实现持续改进,使护理文书书写质量逐年提高。

Nursing records is an important component of the recipients of health care, and it is not only a true reflection of a range of activities carried out by the nurses to the patients, but also a direct evidence of medical disputes. The care record clinical data has 4 properties which contains objective truth, continuous integrity, accurate and timely and standard uniformity. In the event of medical disputes, if the nursing record is lacking in authenticity and integrity, there are many difficulties in proof and even leads to failure proof. So, how to improve the writing quality of nursing records is an important issue which the nursing administrators face. As a consequence, it is necessary for the nursing department to check the quality of the writing records. To the problems, appropriate measures should be taken in order to promote the quality of care writing.