腰椎手术后护理记录缺陷分析

Quality Defects Analysis on Nursing Records after Lumbar Spine Surgery

目的提高腰椎手术后的护理记录的质量。方法调取2014年1月至2014年6月骨科腰椎手术病历,以护理记录书写要求为标准,检查护理记录书写缺陷,并对缺陷进行汇总分析,计算各种缺陷的百分比。结果 86份护理记录有缺陷的护理记录67份,占77.91%。最主要的缺陷是不规范修改,有28份,占有缺陷的护理记录的41.79%。其次是记录不全或漏记17份,占有缺陷的护理记录的25.37%。其他还有记录不及时、用语不规范和医护记录不一致等。结论护理记录的主要缺陷是不规范修改。

Objective To improve the quality of nursing records after lumbar spine surgery. Methods The medical records after lumbar spine surgery in orthopedic department were selected from January 2014 and June 2014. To inspect the writing defects in nursing records with the requirements of the nursing records in this hospital, and make a summarize analysis on the defects and calculate the percentage of them respectively. Results There were 67 cases of nursing medical records existing defects in the 86 cases, which accounting for 77.91%. The main defect was not standardized modification, which were 28 cases and accounting for 41.79%. The second place was 17 cases of incomplete or omission nursing records, which accounting for 25.37%. There were also other defects such as had not finished timely, not standardized words and inconsistent recording between doctors and nurses. Conclusions The main defect of nursing records was not standardized modification.