医学信息
醫學信息
의학신식
MEDICAL INFORMATION
2013年
16期
195-196
,共2页
产科%护理病历%缺陷%规范途径
產科%護理病歷%缺陷%規範途徑
산과%호리병력%결함%규범도경
Obstetrics%Nursing medical records%Defect%Specification
目的分析产科护理病历存在的缺陷问题，并探讨其规范途径。方法以我院产科随机抽查的620例护理病历为研究对象，采用回顾性分析方法对620例护理病历的书写质量进行评价并统计。结果本组620例护理病历中，共发现86例护理病历存在缺陷问题，缺陷率为13.87%。缺陷病历的分布比率由高到低依次为：护理记录单6.45%、医嘱单4.03%、体温单3.39%。其中，护理记录单主要为资料认识不清、漏项、主观判断；体温单主要为与事实不相符；医嘱单主要为执行医嘱时间、内容不符。结论产科护理病历的缺陷率较高，应加强护理病历的规范途径，提高病历质量。
目的分析產科護理病歷存在的缺陷問題，併探討其規範途徑。方法以我院產科隨機抽查的620例護理病歷為研究對象，採用迴顧性分析方法對620例護理病歷的書寫質量進行評價併統計。結果本組620例護理病歷中，共髮現86例護理病歷存在缺陷問題，缺陷率為13.87%。缺陷病歷的分佈比率由高到低依次為：護理記錄單6.45%、醫囑單4.03%、體溫單3.39%。其中，護理記錄單主要為資料認識不清、漏項、主觀判斷；體溫單主要為與事實不相符；醫囑單主要為執行醫囑時間、內容不符。結論產科護理病歷的缺陷率較高，應加彊護理病歷的規範途徑，提高病歷質量。
목적분석산과호리병력존재적결함문제，병탐토기규범도경。방법이아원산과수궤추사적620례호리병력위연구대상，채용회고성분석방법대620례호리병력적서사질량진행평개병통계。결과본조620례호리병력중，공발현86례호리병력존재결함문제，결함솔위13.87%。결함병력적분포비솔유고도저의차위：호리기록단6.45%、의촉단4.03%、체온단3.39%。기중，호리기록단주요위자료인식불청、루항、주관판단；체온단주요위여사실불상부；의촉단주요위집행의촉시간、내용불부。결론산과호리병력적결함솔교고，응가강호리병력적규범도경，제고병력질량。
Objective: to analyze the flaws of the obstetric care medical records and standard way. Methods:620 cases of medical record writing quality of nursing. Results:found that nursing records the defect rate is 13.87%. From high to low in turn is:the nursing record list,orders single 4.03%,body temperature and 6.45% to 4.03%.Nursing record list mainly for the information,understanding unclear items,subjective judgment; Single temperature mainly is not consistent with the facts;The doctor's advice form time,content,mainly to carry out the doctor's advice. Conclusion: obstetric care medical records of defect rate is higher,should strengthen the nursing records normative way,improve the quality of medical records.
