精神科护理文书缺陷研究.docVIP

精神科护理文书缺陷研究 【 】目的调查精神科住院病历中护理文书存在的缺 陷，分析缺陷存在的原因，探讨改进措施，提高护理文书质 量和护理质量。方法组织护理部质控员对我院2010年8月 1日-2011年5月31日精神科入档保存病历，按病案号尾数 为单数的病历，重新进行质量控制，按湖南省2010年7月1 日起实行的新的《病历书写规范与管理规定及医疗质量评定 标准》，对其护理文书记录开展质量评价。结果我院精神科 病历中的护理文书，低级错误较多，且存在书写不完整、不 准确、不真实等问题，优秀率仅为70%。结论护士的法律意 识淡薄，知识贫乏，工作不扎实是造成护理文书缺陷的主要 原因，加强法律知识和业务知识的培训与学习，完善各级质 量管理与控制是提高护理文书书写质量和护理质量的对策。 【关键词】精神科护理文书缺陷分析 分类号：R B 1005-0515 (2011) 7-343-02 Psychiatric care instruments defect analysis Wangzheng Ying Cao Shenghua (Psychiatric Disease Hospital of Hunan Province, Hunan Anhua Anhua 413522) 【Abstract】 Objective To investigate the medical records of psychiatric in-patient care instrument defects, analyze the reasons for the existence of defects, ways to improve measures to improve the quality of care and quality of care instruments. Methods to organize nursing department quality control staff of the hospital August 1, 2010 May 31, 2011 file saved into the medical history of psychiatric, medical record number by the number ending in a single medical record, re-quality control, according to the Hunan Province 2010 January to implement the new “norms and regulations of medical records and medical quality assessment standards,’’ the quality of their care and their documentation to carry out evaluation. Results of psychiatric hospital care in medical instruments, low level of errors, and there is writing incomplete, inaccurate, untrue and other issues, outstanding rate of 70%. Conclusion The nurses legal consciousness, lack of knowledge, care work is not solid is caused by defects in the main instrument to strengthen the legal knowledge and business knowledge, training and learning, improve quality at all levels of management and control is to improve the quality of care and care quality writing instruments response. 【Keywords】 psychiatric nursing defect analysis instruments 2010年7月1日起实行的《侵权责任法》，将医疗责任 损害列为第七章，明确了护理文书（记录）是病历的重要组 成部分，是以客观资料为依据具有法律效应的文件［1］。同 时，护理文书贯穿整个病历的始终，对反映病人的病情、诊 治和转归具有极为重要的参考价值，相关规章对护理文书书 写有严格的规范要求与质量标准［2］，并对