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目的探讨在举证责任倒置下如何提高转科护理文书的相符性。方法随机抽查2007年5～6月归档病案中115份转科病人的护理病历,对书写存在的缺陷进行了分析。结果转科护理文书的相符性较差。检查的115份转科护理病案中,存在缺陷病历18份,占检查病案数的15.6%,共出现缺陷次数37次。结论在举证责任倒置下,加强法律的学习和自我保护意识、加强病历书写的规范化教育、加强工作责任心、加强医护间、护护间的密切合作和沟通、加强护理文书的质量检查是提高转科护理文书相符性的良好对策。
Objective To explore how to improve the conformity of transfer nursing documents under the inversion of burden of proof. Methods A random sample of 115 nursing records of patients with rotavirus in archives from May to June in 2007 was analyzed and the defects of writing were analyzed. As a result, the conformity of transfer nursing documents was poor. Of the 115 cases examined, there were 18 defective medical records, accounting for 15.6% of the total number of medical records examined, and the total number of defects was 37. Conclusions Under the inversion of the burden of proof, we should strengthen legal awareness of learning and self-protection, strengthen the standardization of medical records writing, strengthen the sense of responsibility in work, strengthen the close cooperation and communication between medical care and nursing homes, and strengthen the quality inspection of nursing documents. Good countermeasure of conformity of nursing document.