护理文书书写存在问题的分析及对策

Analysis and Countermeasures of Existing Problems in Nursing Record Writing

目的探讨分析护理病历书写过程中存在的主要问题,研究其中的主要原因,并且提出相应的改进措施,以期确保护理病历书写的质量。方法随机抽取本院2013年1月-2015年1月住院患者的护理病历共600份,分析所有护理病历书写中存在的问题,并且分析病历书写缺陷的原因。结果有226份护理病历存在问题,占37.7%。体温单有问题108次,占有问题的护理病历47.79%。医嘱单有问题38次,占有问题的护理病历16.81%。血糖监测表有问题31次,占有问题的护理病历13.71%。主要问题是病历书写缺乏规范性、护理记录重点内容记录不全、相同患者的医疗护理记录缺乏一致性等。结论护理病历存在的问题,需要加强护士人员培训,加强护理病历写书监督,尽可能减少护理病历书写的问题。

Objective To analyze the main problems in nursing records writing process, research the main reasons, and puts forward the corresponding improvement measures, guarantee the quality of nursing records writing. Methods 600 nursing records are randomly drew from January 2013 to January 2015. Analyze the problems and the cause of the defects of Medical record writing. Results About 226 nursing records have problems, accounting for 37.7%; 108 temperature charts have problems, accounting for 47.79%; 38 physician＆#39;s order sheets have problems, accounting for 16.81%; 31 Blood glucose monitoring tables have problems, accounting for 13.71%. The main problems are the medical record writing lack of standardization, the nursing record is not complete, the medical care in the same patients lack of uniformity, etc. Conclusion We need to strengthen the nurse training, strengthen the nursing records supervision, and minimize the writing problems.