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为了认真贯彻《医疗事故处理条例》,按照《病历书写基本规范》的要求,对我科护理记录进行了多次质量检查,发现了一系列护理记录缺陷:体温单中存在缺项;体温单上数据与护理记录单中的数据不一致;执行医嘱后有漏签名、代签名现象;护理记录中病情描述不全,连续性差,记录不真实、不准确、主观判断多等。分析护理记录缺陷产生的原因:工作责任心不强,对诊疗规范、常规落实不到位;护理人员法律意识淡漠,自我保护意识不强等。针对护理记录缺陷及其原因提出对策:加强护士责任心教育,建立完善的护理规章制度;进行护理法律知识培训,增强法制观念,强化法律意识,规范护理行为;组织学习护理书写规范化和制度,强化正确书写的内容和格式,不断提高护理文件书写水平。
In order to conscientiously implement the “Regulations for the Treatment of Medical Accidents,” according to the “basic norms of medical records,” the quality of care records of our department conducted several checks and found a series of nursing records deficiencies: there is a lack of body temperature list; body temperature on a single Data inconsistent with the data in the nursing record list; after execution of the doctor’s order there is a missing signature, on behalf of the signature phenomenon; nursing records in the description of the disease is incomplete, the continuity is poor, the record is not true, inaccurate, subjective judgments and more. Analyze the causes of the defect of nursing records: the responsibility of work is not strong, nor is the standard of medical treatment and routine implementation, the apathetic awareness of nursing staff and the weak sense of self-protection. In view of the defects of nursing records and their causes, this paper puts forward countermeasures: strengthening nurses’ responsibility education, establishing perfect nursing rules and regulations, training legal knowledge of nursing, strengthening the concept of legal system, strengthening legal awareness and standardizing nursing behavior, organizing standardization and system of nursing writing, strengthening Correctly written content and format, continuously improve the level of nursing document writing.