心脏介入患者护理文件缺陷分析与对策

Analysis and countermeasures on defects of medical care documents for patients with cardiac intervention

目的:分析我科心脏介入患者护理文件书写中常见的缺陷,探讨其原因,提出改进措施,规范护理文件书写方法,提高护理文件书写水平。方法:参照《病历书写规范》抽查我科200份心脏介入患者护理病历进行护理缺陷的检查。结果:护理文件书写中存在的各类缺陷137件次。结论:强化护理人员法律意识,重视业务素质的培养,加大管理力度,规范护理文件书写是提高护理文件书写质量的保证。

Objective：To analyze the defects of medical care documents written for patients with cardiac intervention, discuss the causes, give the improvements and standardize the.writing methods to improve the writing level on medical care files. Methods ：To draw out 200 records in random on patients with cardiac intervention and check the defects according to the ＂Medical Record Written Guideline＂. Results： There were 137 types of defects existing in the writing of nursing files. Conclusion：Should strengthen nursing staff＇s awareness of the law, pay attention to the cultivation of professional quality, improve the management and standardize the writing on nursing files to make sure the improvements on its writing.