手术室护理记录常见问题的分析及对策.docVIP

精品论文 参考文献 手术室护理记录常见问题的分析及对策 杨学玉 (四川省达州市中心医院手术室 四川 达州 635000) 【摘要】 目的：观察手术室护理记录单，对其中所出现的问题进行分析，并研究管理对策、提高护理记录质量。方法：对2011年1月～2014年12月记录归档的1648份手术室护理记录单，检查其中所出现的问题并归类分析其原因，根据问题与原因研究管理对策。结果：通过对手术室护理记录进行检查，发现其中主要存在项目填写不完整、记录内容错误、用语不准确、代签名（漏签名）、书写不规范等问题，并分析其原因以研究相应对策。结论：手术室护理记录无论对患者还是院方、对临床治疗还是法律效力，均有着重要的作用与意义，目前手术室护理记录仍有一定的欠缺与问题，需要探明原因，分析研究其对策，进一步提高护理记录质量。 【关键词】 手术室；护理记录；问题分析；对策 【中图分类号】R471 【文献标识码】A 【文章编号】2095-1752（2015）21-0025-02 Operating room nursing records for common problem analysis and countermeasure 【Abstract】 Objective To observe the operating room nursing record sheet, carries on the analysis to the problems which appear, and Study on the management strategy, improve the quality of nursing records. Methods In January 2011 to 2014 December documented the 1648 copies of operating room nursing records, which examines the problem and classified analysis of the reasons, according to the problems and reasons of the management countermeasures. Results Through the inspection of operating room nursing records, which mainly exists project to fill in incomplete, record the contents of the error, language is not accurate, on behalf of the signature of leakage (signature), writing non-standard problems, and analysis the reason to study the corresponding countermeasures. Conclusion: Operating room nursing records both for patients and for the hospital, to clinical treatment or legal effect, have a vital role and the significance, at present operating room nursing records still some deficiencies and problems, need to explore the reasons, analysis and research the countermeasures to further improve nursing quality records. 【key word】 operation room; nursing records; problem analysis; Countermeasures 手术室护理记录是由巡回护士完成，用来将患者的整个手术过程中所涉及的护理操作、相关制度执行以及相关器械、物品清点等一系列情况完整记录的临床文书。这是一份对于手术护理过程的客观、真实记录，作为原始病历资料可以对患者治疗方案进行回查及进一步安排、调整，同时亦是在治疗过程中出现纠纷进行核查的重要依据，具有重要的法律效力[1]。这份记录不仅是对手术患者的安全保障，亦是对护理人员的自我保护，因此需要注意该文件内容的真实性、完整性与规范性。为了进一步提高手术室护