393份转科死亡病历护理文书书写存在的问题及对策

Problems and Countermeasures in Writing Nursing Documents of 393 Cases of Final Death in Transferred Department

目的:本文探讨了393份转科死亡病历护理文书书写方面存在的问题及对策,发现提高护理文书书写质量非常重要,特别是转科死亡病历护理文书书写质量。由于涉及两个或两个以上的科室,容易在书写方面出现一些问题,如缺记录、相符性较差等。探讨方法:回顾性调查,总结分析我院近年来393份转科死亡病历护理文书书写质量,对存在的问题进行总结分析。结果:体温单、医嘱单、护理记录单及各专科护理记录单等均存在不同程度的问题,有潜在的医疗安全隐患。结论:应加强转科护理文书的环节质控检查,督促相关科室加强管理,及时检查补充完善,达到提高护理质量及防范医疗风险的目的。

Objective: To explore the problems and countermeasures in the writing of nursing documents of 393 death cases in transfer departments, and to find out the importance of improving the writing quality of nursing documents, especially the quality of nursing documents of death cases in the transfer department. As it involves two or more than two departments, it is easy to have some problems in writing, such as lack of records, poor consistency, etc. Methods: A retro-spective investigation was conducted to summarize and analyze the quality of nursing documents of 393 death cases in our hospital during the past three years, and the existing problems were sum-marized and analyzed. Results: There were some problems in temperature sheet, doctor’s order sheet, nursing record sheet and nursing record sheet, which had potential medical safety problems. Conclusion: The quality control of nursing documents should be strengthened, and the related de-partments should be supervised to strengthen the management, and the timely inspection should be completed to improve the quality of nursing and prevent medical risks.