1860份产科病案护理记录缺陷分析与对策

Defects Analysis and Countermeasures of Nursing Record about 1860 Medical Record in Obstetrical Department

目的提高护理记录质量,减少护理记录缺陷引起的医疗纠纷。方法分析某医院产科出院病案1860份护理记录书写质量,对记录中存在的缺陷进行归类,分析并提出防范对策。结果检查病案中有586份护理记录存在缺陷,占病案数的31.5%,共15项686处。结论提高护理人员法律意识及综合素质,加强医护沟通,实行全程,全员参与质控,可持续提高护理质量,减少医疗纠纷。

Objective To improve quality of nursing record for reducing the medical tangle causing by nursing record.Methods An analysis on writing quality of nursing record about 1860 medical record in obstetrical department,classifying the defects in nursing record,analyzing and putting forward prevention countermeasures.Results There are 586 nursing record exist defects,which accounts for 31.5% of all medical record.There are 686 defects classifying 15 kinds.Conclusion The ways of improving nursing quality and reducing medical tangle are law consciousness and comprehensive quality improvement of nurses,medical staff and patients communication strengthening and participation of quality control by all the staff.