探讨综合内科重危病人护理记录问题与对策.docVIP

精品论文 参考文献 探讨综合内科重危病人护理记录问题与对策 芦山县人民医院；四川雅安625600） 摘要 目的 探讨医院综合内科重危病人护理记录过程中存在的问题及对策。 方法 选择我院综合内科2015年1月至12月150例重危病人电子病历护理记录进行分析、汇总，找出护理记录中存在的问题，寻找对策，为护士重危病人的护理记录提供良好的方法，尽可能地提高重危病人的护理记录书写质量。 结果 护理记录存在问题88份，通过分析存在问题的原因分析，提出了改进对策，提高了护士法律意识，护理部有目的、有方向地对护士的综合素质和专业技能进行培训。结论 实行科学化的护理记录方法，提高了我院的护理记录质量，减少了护患纠纷的发生，加强护患沟通及强化护理记录质量监控，以确保护理安全管理。 关键词 内科重危病人；护理记录；问题；对策 Discussion comprehensive medical critically ill patient care record problems and countermeasures Li Yulan Lushan County Peoples Hospital of Lushan County, Yaan City, Sichuan Province Zip code 625 600 Abstract:[Objective] To investigate the Comprehensive Hospital medical problems and countermeasures in critical patient care records exist in the process. [Method] our hospital comprehensive medical January 2015 to December, 150 cases of critically ill patients electronic medical records nursing records were analyzed, summarized, identify the problems in nursing records, to find countermeasures for nurses in critical care patient records provided good approach, as much as possible to improve the care of critically ill patients record the quality of writing. [Results] 88 parts nursing record problems, cause analysis by analyzing the problems of proposed improvement measures to improve the legal awareness of nurses, nursing a purpose and a direction to the overall quality and professional skills of nurses training. [Conclusion] implementation of scientific nursing recording methods to improve the quality of nursing records in our hospital, the nurses and patients to reduce the incidence of disputes, strengthening the nurse-patient communication and strengthen the quality of nursing records control to ensure the care and safety management. Keywords medical critically ill patients; nursing records; problem; countermeasure 随着社会的发展，国家法制日益健全，人们的法律意识也逐步增强。新颁布的“侵权责任法”既增强了对患方的保护[1]，又明确了医护人员的责任。举证倒置的实行，更进一步要求医护记录做到完善、完整、科学化。因为护理记录作为医疗记录的重要组成部分，它是患者在接受医疗护理过程中的真实写照，在法律上的地位是不可替代的的地位，它是处理医患关系和护患关系的重要依据。 1 资料与方法 1.1