CAJ | 학술논문

目的：探析肿瘤微创介入科护士书写整体护理表格的常见问题及影响因素，制定改进护理文件书写的对策。方法对我院2012年9月-2014年5月肿瘤微创介入科的护理文件1536份进行质控检查对其中存在问题的230份进行分析、统计及调查，分析书写护理文件的常见质量问题，并制定相应整改措施。结果护理文件230份中，常见问题为体温单画错及漏项，护理记录单护士漏签字、有涂改及页码标错，健康教育记录单责任护士漏签名及空项，入院评估单有漏记和涂改。结论增强护理人员的法律意识、增强管理质量监控、简化护理文件的书写格式可提高书写护理文件的质量。进行责任护士自查、护理文件检查小组组长检查、护士长质控把关等三级自查，最后由护理部质控检查，分析书写护理文件的常见质量问题，并制定相应科学对策。
목적：탐석종류미창개입과호사서사정체호리표격적상견문제급영향인소，제정개진호리문건서사적대책。방법대아원2012년9월-2014년5월종류미창개입과적호리문건1536빈진행질공검사대기중존재문제적230빈진행분석、통계급조사，분석서사호리문건적상견질량문제，병제정상응정개조시。결과호리문건230빈중，상견문제위체온단화착급루항，호리기록단호사루첨자、유도개급혈마표착，건강교육기록단책임호사루첨명급공항，입원평고단유루기화도개。결론증강호리인원적법률의식、증강관리질량감공、간화호리문건적서사격식가제고서사호리문건적질량。진행책임호사자사、호리문건검사소조조장검사、호사장질공파관등삼급자사，최후유호리부질공검사，분석서사호리문건적상견질량문제，병제정상응과학대책。
Objective To explore and analyze the common problems of holistic nursing forms and writing of nurses in tumor mini-mally invasive interventional radiology, with providing countermeasures to improve the writing of nursing documents. Methods 1536 nursing documents in tumor minimally invasive interventional radiology of our hospital from September 2012 to May 2014 are selected for quality control checks. In which, 230 documents with problems were analyzed and researched. Common quality is-sues in writing nursing documents were analyzed, with countermeasures provided. Results In 230 nursing documents, common problems includes wrong drawing or miss items in body temperature form, correction, wrong page number, or no signature in nurs-ing records, no signature or empty item in health education records, miss item or correction in admission assessment. Conclusion Enhancing the legal awareness of nursing personnel, strengthening quality control management, and simplifying nursing document writing format can improve the quality of nursing documents. Perform three level checking, including self-checking of responsible nurse, team leader checking nursing documents, quality control of head nurse, and quality control of nursing department, to ana-lyze common quality problems in writing nursing documents and make corresponding countermeasures.