1058份外科出院病历医嘱单缺项及对策

On the omitted items of doctor's advice in the surgery medical records for 1058 cases of hospital discharge and the strategies

目的:总结医嘱单在临床应用中易发生的缺项及对策。方法:在医护人员中,认真落实查对制度、重视病历书写的法律认知、病历书写规范化培训、科室严把护理书写三关、护理部加强三级质控书写指导。结果:干预前医嘱缺项病历占33.1%,干预后占7.6%。结论:医嘱单在临床应用工作中,通过提出干预对策后,明显减少医嘱单发生记录缺项,提高了医护人员病历书写质量。

[Objective]It concludes the items of doctor's advice which are easily left out in medical records at clinical stage and the strategies.[Method]For medical personnel,the medical-records-checking system should be seriously implemented,and the importance of writing medical records on a legal basis,and the training for writing standard medical records should be emphasized. The three-level nursing writing should be close checked in the department,and the guidance for the writing of three-level quality control should be reinforced in the nursing department.[Result]the medical records with omitted items of doctor' s advice account for 33.1%before the interfere,and 7.6%after the interfere.[Conclusion]In the work of clinical practice,with the interfere strategies,there is a striking decline in the omission of items in medical records,and a progress in the writing quality of medical personnel.