护理记录中潜在的法律风险及对策

On the Potential Legal Risk in Nursing Records and the Countermeasures

目的:探讨护理记录中潜在的法律风险及对策,提高护理质量,减少差错事故及护理纠纷发生率。方法:将某医院2014年8月至2016年8月收治的2 571例住院患者作为研究对象,利用回顾性方法对患者的住院病历资料中潜在的法律问题展开分析。结果:在所选取的2 571份患者的临床护理记录中,共出现潜在法律问题24例次,依次为涂改及缺空现象9例次,占37. 5%;记录不真实、不及时、不全面5例次,占20.8%;医嘱与护士执行时间不吻合3例次,占12.5%;医、护记录不吻合3例次,占12.5%;护理记录之间不衔接2例次,占8.3%;护理记录不具体、漏记重要内容1例次,占4. 2%;输液滴速与输液完的时间不吻合1例次,占4. 2%。结论:进行护理记录时要加强对护理人员的法制教育,强化法律意识;增强医护沟通,保障医护记录的一致性;强化专业理论学习,保障护理记录的及时性与准确性;开展护理记录质量管理三级监控措施,提高护理文书书写质量要求,降低护患纠纷发生率。

Objective： To raise nursing quality, reduce error and accidents and the incidence of nursingdisputes by discussing the potential legal risk in the nursing records and the countermeasures. Methods： All 2 571inpatients who were admitted from August, 2014 to August, 2016 into our hospital were chosen as the object ofstudy, the potential legal issues in the patients＇ inpatient medical records were analyzed using retrospective method.Results： In clinical nursing records of 2 571 patients who were selected, there were 24 cases showing potentital legalissues, they were nine cases of altering and vacancy, which held 37.5%; five cases of the records which were nottrue, timely and complete, and they occupied 20.8%; three cases in which medical advices were not identical to thenurses＇ execution time, and 12.5%; three cases that medical records couldn＇t fit nursing records, and 12.5%; twocases that nursing records couldn＇t connected and they occupied 8.3%; one case of nursing records that wasn＇tconcrete and important contents were lacked, which held 4.2%; one case that infusion velocity couldn＇t fit the time offinishing the infusion, and it held 4.2%. Conclusion： When performing nursing records, we should enhance legaleducation to nursing staffs, and their legal sense, strengthen doctor-nurse communication, ensure the uniformity inmedical and nursing records, intensify professional theorectical study, guarantee the timeliness and accuracy ofnursing records, launching three-level monitoring measures of nursing records quality management, raise qualityrequirements for writting nursing documents and decrease the incidence of nurse-patients disputes.