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目的:护理文件可以看出护士执行医嘱的情况,患者治疗的情况,以及护理人员对患者的病情观察等。分析护理文件中存在的问题,并提出改进的办法和措施。方法:收集我科2014年6月到2015年6月期间,产生的1127份护理文书,然后分析存在的问题,提出解决的对策。结果:经过分析研究,发现了在护理文书中经常存在的七个问题,提出加强在职教育、增强护理人员法律意识,实施岗位培训,规范护理文件书写等对策。结论:定期对护理文件进行分析,能够针对存在的问题提出可行性的改进办法,促进护理文书质量的提升。
Objectives: Nursing documents can be seen nurses to implement the doctor’s advice, the patient’s treatment, as well as nurses on the patient’s condition observation. Analyze the problems in nursing documents and propose ways and measures for improvement. Methods: A total of 1,127 nursing documents were collected from June 2014 to June 2015 in our department, then the existing problems were analyzed and the countermeasures were put forward. Results: After analyzing and researching, we found seven problems that often exist in nursing documents, and put forward some countermeasures such as strengthening on-the-job education, enhancing legal awareness of nursing staff, implementing job training and standardizing the writing of nursing documents. Conclusion: The regular analysis of nursing documents can provide feasible solutions to the existing problems and promote the improvement of the quality of nursing documents.