返回 2008年第31卷第3期 目录

危重病人护理记录缺陷分析及干预策略

黄永丽，刘乾惠，陈华容

(泸州医学院附属医院心内科CCU，四川泸州 646000)

摘 要 目的：了解危重病人护理记录中的缺陷，分析原因，主动干预，提高护理记录质量。方法：对471份危重病人护理记录单逐项检查，将其缺陷进行统计分析。结果：查出缺陷269处，表现为生命体征与体温单不符；漏记；记录不连贯、不完整、未体现专科特点；记录时间与执行时间不符；主观记录等。确立其原因，提出针对性的干预策略。结论：加强护士职业道德、法律知识教育和专业知识、技能培训，增进医、护、患沟通，合理调配人力，全程质量控制，确保护理记录质量，防止护理纠纷。

关键词 护理记录；缺陷；干预策略

AN ANALYSIS ON THE DEFICIENCIES EXISTED IN THE NURSING RECORDS OF CRITICAL PATIENTS AND ITS COUNTERMEASURES

Huang Yongli,et al

Department of Cardiology,the Affiliated Hospital of Luzhou Medical College

Abstract Objective:To find out the deficiencies existed in the nursing records of critical patients.To analyze the reason of the deficiencies and intervene actively to improve the quality of nursing records.Methods:471 critical patients’nursing record sheets were checked and the deficiencies were analyzed.Results:269 pieces of deficiencies were found . The deficiencies mainly lay in the disaccords between the vital sign and temperature sheets, fail to record and incomplete record, disaccords between nurse recording time and conducting time, subjective record ,etc. The reasons for deficiencies have been found and corresponding countermeasures have been proposed. Conclusion:It is important to enhance the quality of nursing records and prevent nursing dispute through strengthening the education of nursing professional moral , knowledge of specialty and related law, improving the communication among the doctors,the nurses and the patients,and arranging the manpower reasonably .

Key words Nursing record; Deficiency; Countermeasures