基层医院护理记录单存在纠纷隐患研究及对策.docVIP

基层医院护理记录单存在纠纷隐患研究及对策【摘要】 目的 分析护理记录单纠纷隐患产生原因，并探讨相应防范对策。方法 用统一的质量标准检查952份护理记录单，对存在的缺陷用表格形式按百分比分类列出。结果 通过原因分析，认为护理记录单存在的纠纷隐患与字迹潦草、涂改刮痕，记录简单、陈述不清，记录不全面、缺乏连续性，医护记录不一致，未使用医学术语，用符号代替文字，签名不规范，重抄等因素有关。结论 加强护士法律知识、业务知识的学习，加强医护交流，通过多环节质量监控，应用奖惩机制，合理使用人力资源等防范措施来应对护理记录单存在的问题，从而提高护理质量，避免医疗纠纷的发生。 【关键词】 护理记录单；原因分析；防范对策 Basic unit hospital care label existence dispute hidden danger analysis and countermeasure SUN Hua.Shandong Coal Linyi Hot spring sanatorium Gynecology and Obstetrics Department，Linyi 276032，China 【Abstract】 Objective The analysis nursing label dispute hidden danger has the reason，and discusses the corresponding guard countermeasure.Methods Inspects 952 nursing labels with the unification quality specification，lacks to the existence hidden lists with the tabular form according to the percentage classification.Results Through the reason analysis，thought that the nursing label existence the dispute hidden danger and the sloppy handwriting，the modification scratch，the record is simple，the statement is unclear，records，the deficient continuity not comprehensively，the medical treatment and nursing record is inconsistent，has not used the medicine terminology，replaces the writing with the mark，signs not standard，reproduces and so on factors to concern.Conclusion Strengthens nurse the legal knowledge，the professional knowledge study，strengthens the medical treatment and nursing exchange，through the multi-link quality monitoring，the application rewards and punishment mechanism，uses measures and so on human resources to deal with the nursing label existence reasonably the question，thus the enhancement nursing quality，avoids the medical disputes occurrence. 【Key words】 Nursing label；Reason analysis；Guard countermeasure 2002年9月1日开始实施的《医疗事故处理条例》第1次在法规中明确了护理记录是病历的重要组成部分，并以客观资料作为法律性文件，为护患双方提供了法律保证及举证依据。《医疗事故处理条例》第十条规定了患者有权复印的病历资料中如体温单，医嘱单，护理记录单等均属护理记录书写的病历资料。护理记录单是指护理人员对患者住院期间护理过程的真实记录，是反映护士素质和护理质量的重要方面，是法律证据之一。为保护医患双方的合法权益，避免医疗纠纷的发生，护理记录单书写质量显得尤为重要。目前的护理记录单存在着一些纠纷隐患，