护理文件书写存在问题的分析与对策

Nurses the document writing existence question the analysis and the countermeasure

随着人们生活水平的不断提高及法律意识的不断增强,加之〈医疗事故处理条例〉的颁布和实施,护理记录成为规范性、法律性的护理文件之一.〈条例〉的第2章第10条明确规定,病人有权复印所有有关的护理文书.一旦发生医疗纠纷,医院需自证无错,必须承举证责任,即举证责任倒置.因此要求护理记录必须真实、准确、完善,而且严禁涂改、伪造.但在日常工作中护理记录仍存在一些问题,因此对此进行总结、分析,提出相应对策.

Along with the people living standard unceasing enhancement and the legal consciousness unceasing enhancement, adds ＂Incident of malpractice Processes Rule＂ the promulgation and the implementation, nurses the record to become one of regulated, law nursing documents. ＂Rule＂ 2nd chapter of 10th stipulated explicitly that, the patient is authorized to photocopy all related nursing copy clerk. Once has the medical dispute, the hospital must from prove correctly, must receive presents evidence the responsibility, namely presents evidence the responsibility inversion. Therefore requests tO nurse the record to have real, to be accurate, to be perfect, moreover forbid strictlys the modification, fabricating. But nursed the record in the routine work still to have some problems, therefore carried on the summary, the analysis regarding this, proposed the corresponding countermeasure.