Critical patient care records and Analysis of problems and improvement measures.docVIP

 PAGE \* MERGEFORMAT 8 Critical patient care records and Analysis of problems and improvement measures Author: Fu Jia, Han Yinghua, Wang Li, flowers, Wei Hong, Wang Xianling [Keywords] critical patient care records Critical patient care record is under doctor’s orders and nurses in critical condition for the process of care during hospitalization in patients with objective records lt;lt;Regulations of Medical Malpracticegt;gt; Article clearly recorded in the medical component of care in an important position. In order to further improve care normative and rigor, reduce defects and disputes, clinical care, hospital care and quality control group over the years insist on regular and irregular care instruments, inspection, now recorded in the current critical care problems and cause analysis summarized below. 1 problem Records are not detailed and not rigorous 1.1 Record the treatment contents, basic care, life care little or no content in the inspection found that critically ill patients nursing records (hereinafter referred to as heavy protection orders) in the treatment of multiple prescription for the nurse executive at the record, such as recording “prescribed suction , the white foam-like, thin, “etc., and for patients with warm water to scrub the face, hands, or to help stand up to observe the situation and organize sheets of skin pressure, maintain a comfortable supine behavior of such care are not recorded or records are not detailed, non-specific, data record lack of rigor, such as one case a single death in patients with heavy care patients with respiratory rate recorded 22 times per minute, while in “condition and treatment” column records of patients’ difficulty in breathing, prescribed oxygen inhalation, 3 L / min “, because there is no description of breathing pattern, respiratory rate can not be proven only from the time patients have clinical manifestations of dyspnea, as a dispute lay hidden. 1.2 lack of integrity and conclud