主管:国家卫生健康委员会
主办:国家卫生健康委医院管理研究所
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• 2015中国护理管理大会专题 • 上一篇    下一篇

基于信息技术的CCU护理记录缺陷分析与对策

陈延亭 林芳   

  1. 中日友好医院CCU
  • 出版日期:2015-08-25 发布日期:2015-08-25

Analysis of the defects and countermeasures of nursing records in the CCU

  • Online:2015-08-25 Published:2015-08-25

摘要: 收集我院冠心病重症监护病房(CCU)2012 年8 月至2014 年6 月护士长在日常护理检查工作中发现的存在书写缺陷的护理病历共233 份,采用访谈的方法对可能存在的原因进行分析。结果发现,护理记录缺陷主要包括:护理记录项目缺失或存在漏项情况、书写不规范、常规护理项目描述不详细、存在错别字、护理记录前后不一致、缺乏专科重点观察项目等。分析其原因可能有护理人员法律意识淡薄,对护理文书的重要性认识不足;缺乏专科护理知识;护士的工作琐碎繁忙,导致护理记录不及时,而在补充记录时很容易造成项目缺失或失真的情况;电子病历系统有待于进一步完善。提示应针对以上原因采取整改措施,包括加强护理人员法律知识、专业基础的学习,不断完善信息系统,以减少护理记录缺陷的发生。

Abstract: The convenient sampling methods was used to collect nursing records with writing defects in the CCU from August 2012 to June 2014, and were interviewed to explore the possible reason. The reasons of nursing record defects mainly included the item missing, nonstandard recording, the routine nursing record not detailed, wrong character, inconsistently recording,lack of specialized subjects in the recording. The properly reasons were nurses’ legal consciousness faint, lack of understanding of the importance of nursing recording, lack of the specialized nursing knowledge. Nurses’ work were busy and trivial, resulting in nursing records not in time, and supplement the record was easy to cause loss or distortion of the items. Electronic medical record system needs to be further improved. Strengthening the study of legal knowledge and professional nursing foundation, perfecting the information system, can effectively control the nursing records defects in the busy nursing daily work.