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目的:探究神经外科护理记录中所存在的问题,提出有效的管理对策,以期提高护理记录的质量。方法:选择浙江省湖州市第一人民医院2013年4月~2014年4月期间住院的220例神经外科患者,对其出院病历进行整理分析,对所有病历按照《护理文书》书写规范的各项要求进行仔细核对。就核对检查过程中所发现的问题进行记录分析。结果:在这220份病历中,发现有62份病历存在着问题,占总数的28.18%。在发现的62份问题病历中,共检查出116处护理记录缺陷。结论:加强医护之间的沟通和交流,提高护士的业务能力,增强法律意识,对逐步改善和提高护理记录的书写质量有着十分重要的意义。
Objective: To explore the problems in neurosurgery nursing records and to put forward effective management strategies to improve the quality of nursing records. Methods: A total of 220 neurosurgery patients hospitalized in First People’s Hospital of Huzhou, Zhejiang Province from April 2013 to April 2014 were selected and their medical records were collected and analyzed. All medical records were recorded according to the norms of Nursing Documents Asked for careful checking. Record and analyze the problems found in the checkup process. Results: Of the 220 medical records, 62 medical records were found to be problematic, accounting for 28.18% of the total. Of the 62 problem medical records found, a total of 116 nursing record defects were detected. Conclusion: To strengthen the communication and exchange between doctors and nurses, improve nurses’ professional ability and enhance legal awareness are of great significance to gradually improve and improve the quality of nursing record writing.