对护理病历实施风险管理的探讨

On the risk management of nursing medical records

目的:探讨风险管理在防范护理病历缺陷中的作用。方法:随机抽取2003～2004年内科、外科、妇产科护理病历各300份,对其护理病历记录按浙江省《病历书写规范》进行评价及质量分析,提出风险管理对策,对护理病历的高风险的护理行为制订风险管理制度,对全院护士进行法律知识教育,专业知识以及护理记录相关培训等。结果.2005年同期护理病历质量明显提高。结论:实施风险管理1年,提高全院护理人员法律意识及自我保护意识,对保证护理记录的及时性、有效性、客观性、真实性、完整性起着重要作用。

[Objective]To discuss the function of risk management in preventing the deficiency of nursing medical records. [Method]300 random medical records between the year of 2003 to 2004were selected respectively of intern medicine,surgery and gynaecology and obstetrics.According to the Zhejiang Medical Records Standard for Writing,these medical records were evaluated and their quality were analyzed.The strategies for risk management are suggested,and a risk management system has been set up to bring the high risk behaviors in nursing medical records under control.All the nurses in the hospital were educated in laws,professional knowledge and received some relevant nursing records training.[Result]The quality of nursing medical records has an obvious improvement during the corresponding period in 2005.[Conclusion]The nursing personnel's awareness of law and self-protection has been developed since the risk management was conducted,which is significant to ensure the timeliness, effectiveness,authentity,and integrity of nursing records.