护理病历常见缺陷与改进措施

Common Defects and Improvement Countermeasures of Nursing Medical Records

目的提高护理病历质量。方法对1000份护理病历进行检查,分析缺陷的原因并采取改进措施。结果常见缺陷有项目填写不全、护理记录与医疗记录不相符、拷贝等,分析原因是重视程度不够、法律意识淡漠、质控力度不够,采取的改进措施是加强在岗护理培训,加强病历书写中的质量环节控制,强化法制观念,提高护士法律和质量意识。结论通过采取有效措施,使护理病历的缺陷得到了很好的解决,提高了护理文书书写质量,避免了医疗护理纠纷的发生。

Objectives to improve quality of nursing medical records.Methods 1000 nursing medical records are examined in order to analyze the reasons of defects and to adopt improvement countermeasures.Results The common defects are incomplete items filling,nursing records without conforming to medical records with copy and etc;the reasons of that are insufficient value,faint legal consciousness,insufficient quality control.The improvement countermeasures are to strengthen on-the-job nursing training,quality segment control in medical records writing and legal concept and to improve nurses＇ legal and quality consciousness.Conclusions It applies effect countermeasures to settle defects of medical records well,improving writing quality of nursing document for preventing the occurrence of medical nursing tangle.