摘要
为提高特护记录质量,对某“三甲”医院部分病房采用随机抽样方法,抽样、评审了360个班次的特护记录,并对涉及记录的42名护士进行问卷调查。调查结果显示:生命体征、出入量数字记录和卷面分值最高;病情变化、治疗处理经过的记录不完整,分值最低。护士对特护记录是一个重要的医疗文件认识不足,只有7.1％的人提到它是具有法律依据的文件;护士长在此方面管理水平有待提高;在危重病人的护理上也没有体现对护理程序的应用等。因此,尽快提高特护记录质量势在必行。
To enhance the quality of special nursing record, we sampled randomly 360 special nursing records in some wards in the tertiary hospitals of A grade, and we investigated 42 nurses related with these records with questionnaire. The result shows: the scores of life sign, input - output number record and files are the highest; but the record that describes changing of an illness' state and process of curing the ilness is incomplete, and their scores are the lowest. The nurses were unaware that the record of special nursing is an important medical file. Only 7. 1% nurses thought it was a kind of law file. The management level of the charge nurse should be improved in the record of special nursing. Nursing procedure has not been applied in the nursing of the patients with serious diseases. Therefcre, it is necessary to enhance the quality of special nursing record at present.
出处
《中国医院管理》
北大核心
2001年第12期27-28,共2页
Chinese Hospital Management
