内科危重护理记录书写存在问题及改进效果分析

目的规范危重护理记录书写内容、格式,使之动态反映病情变化,为医疗提供依据,提高书写质量,承担起法律上的举证责任。方法于06年选择病例46份,查找存在问题,针对首次护理记录,转科小结,转入记录,出院记录,抢救记录,病情过程记录,进行内容及书写顺序的规范,通过讲座、检查、病历展评等方式促进书写规范化,选择07、08年10月各50份病历进行对比研究。结果 07年度与06年度护理记录质量有显著性差异,08年度与07年度护理记录质量有显著性差异。结论通过明确规范、学习与检查,可有效地提高危重护理记录书写质量,随着时间增加,书写质量可进一步提高。

Objective To give specifications for the writing formats and contents of the nursing records,so that the records can show the change of the conditions of the illness promptly and clearly.Such kind of records can be reference and evidence for the therapy and treatment,and can be very important evidence for the law suits too.Methods In 2006,we selected and studied a sample of 46 patient records,and found out the problems in them,then gave specifications for the contents and writing orders of the nursing records,section-transfer conclusions,hospital-transfer-in records,discharge records,emergency treatment records,and the records of the course of the illness.The specifications are promoted and enforced by giving lectures,examinations,and appraising through comparisons.We chose 2 samples of 50 records each in October of 2007 and 2008,respectively,and compared them with the sample of 2006.Results Significant differences are found among the samples of the three years.Conclusion With the specifications carried out,the quality of the medical records is improved effectively,and will be better with more effort.