急诊抢救病历医护记录矛盾的管控

Management of inconsistencies of medical records in emergency department

目的探讨急诊抢救病历中医护记录矛盾的成因与对策,提高医护记录的一致性。方法对急诊抢救病历进行逐一查阅,找出医护记录矛盾之处,查找原因,并采取针对性措施实施管控,进行管控前后的对照分析。结果管控前急诊抢救病历医护记录不一致问题非常严重,138份病历中有67份存在不一致问题,高达48.55%;不一致问题主要在于关键时间点、对病情的描述、医嘱开出与执行时间及重要的抢救治疗措施等医护记录有矛盾;管控前后医护记录不一致情况比较,差异有统计学意义(P<0.01)。结论加强医护之间的有效沟通,控制关键时间点,规范医疗护理记录书写与核对,完善相关的工作流程,加强对急诊医护人员的业务知识和法律法规的学习等,有效控制医护记录矛盾的现象发生。

Objective To explore the causes of inconsistencies of emergency medical records, and to keep doctors and nurses consistent in documentation. Methods The emergency medical records were checked and reviewed. The discrepancies in doctors＇ and nurses＇ documentation were identified and the causes were analyzed. From then on appropriate measures were taken to control the discrepancies in doctors＇ and nurses＇ documentation. Results The discrepancies in doctors＇ and nurses＇ documentation were very serious. Of 138 emergency medical charts, 67 were found to be inconsistent ,up to 48. 55%. The inconsistencies were mainly manifested in the documentation of key time point, the description of patients＇ condition, the time when doctors wrote down an order and when nurses executed an order , and in important treatment measures , etc. The rates of inconsistencies of medical records before and after management were significantly different （P〈0.01）. Conclusion The inconsistencies of emergency medical records can be effectively avoided by strengthening effective communication between doctors and nurses, controlling the key time point, standardizing writing and checking of medical records, formulating the relevant work processes of emergency rescue, and enhancing medical Professionals＇knowledge of laws.