180份护理文书中存在的问题及对策

Problems of 180 Nursing Records and Countermeasures

目的提高护理文书的质量,以保证各种护理文书的真实性和科学性,避免发生护理纠纷。方法自2010年起通过对在院及出院病历文书的检查,对查出的问题及其原因进行分析、整改。针对查出的问题进行分析指导,组织护士学习并掌握护理文书书写规范;加强护理文书的检查力度,对护理文书中存在的各项问题,及时准确地反馈给护士,督促其改进。结果有效地提高了护理文书的总体质量,基本达到护理文书的书写规范要求。结论增强法制观念,提高护理人员自我保护意识,保证护理文书书写规范,加强医护沟通,保证医护记录的一致性,达到保护护患双方利益的目的。

Objective To improve the quality of nursing records, ensure the science and authenticity of nursing records, and avoid the nursing disputes. Methods From 2010, the medical history documents were inspected to analyze the problems and the causes for rectification. With the analysis and guidance of identified problems, we organized nurses to learn and master the writing specifications of nursing documents; strengthened the inspection of nursing documents, timely and accurately fedback the problems of nursing documents to nurses, and urged for improvement. Results The overall quality of nursing documents was effectively improved, which basically reached the writing specification requirements of nursing documents. Conclusions We should strengthen the concept of law, improve the nurses＇ awareness of self protection, ensure the nursing document writing specifications, strengthen the communication between doctors and nurses, ensure the consistency of medical records from doctors and nurses, and reach the aim of protecting the interests of nurses and patients.