危重病人护理记录存在的缺陷及其相关因素分析

A study on the defect in the nursing records of critical patients and relevant factors

为了提高危重病人护理记录的书写质量 ,对 3所三级甲等医院 2 2个病区的危重病人护理记录进行随机抽样调查 ,对危重病人护理记录中出现问题所涉及的护士进行分析。调查结果表明 :出现的危重病人护理记录问题主要分为治疗记录不准确、病情观察不连续、医学术语不规范、记录与实际不符以及未签名 5类。这些问题的出现与护士的年龄、学历、所在科室等因素有关 ,且不同科室的危重病人护理记录问题有显著性差异。因此 ,为了提高危重病人护理记录质量 ,针对不同护士进行有针对性的护理文件书写培训十分必要 ,同时制定全国统一的护理记录标准是目前提高护理医疗文件质量的当务之急。

To improve the quality of writing in critical patients’ nursing records.The critical patients’ nursing records from 22 units in the 3 hospitals which are the first level of Grade-3 were randomly sampled.The defects in the nursing records and the revolved nurses were analyzed.The results indicated that the main defects included the following 5 aspects:nursing record was not accurate;observation of the patient was non-continued,medical terms using was not standardize, the record didn’t reflect the fact, and lack of the signature.The defects were related to the nurses’ age,education and different departments they work.Also,there was significant difference between distinct departments in critical patients’ nursing records.It is necessary to provide training for the nurses in writing the nursing documents and establish national standard in nursing records,so as to improve the quality of critical patients’ nursing records.