CAJ | 학술논문

目的：观察手术室护理记录单，对其中所出现的问题进行分析，并研究管理对策、提高护理记录质量。方法：对2011年1月～2014年12月记录归档的1648份手术室护理记录单，检查其中所出现的问题并归类分析其原因，根据问题与原因研究管理对策。结果：通过对手术室护理记录进行检查，发现其中主要存在项目填写不完整、记录内容错误、用语不准确、代签名（漏签名）、书写不规范等问题，并分析其原因以研究相应对策。结论：手术室护理记录无论对患者还是院方、对临床治疗还是法律效力，均有着重要的作用与意义，目前手术室护理记录仍有一定的欠缺与问题，需要探明原因，分析研究其对策，进一步提高护理记录质量。
목적：관찰수술실호리기록단，대기중소출현적문제진행분석，병연구관리대책、제고호리기록질량。방법：대2011년1월～2014년12월기록귀당적1648빈수술실호리기록단，검사기중소출현적문제병귀류분석기원인，근거문제여원인연구관리대책。결과：통과대수술실호리기록진행검사，발현기중주요존재항목전사불완정、기록내용착오、용어불준학、대첨명（루첨명）、서사불규범등문제，병분석기원인이연구상응대책。결론：수술실호리기록무론대환자환시원방、대림상치료환시법률효력，균유착중요적작용여의의，목전수술실호리기록잉유일정적흠결여문제，수요탐명원인，분석연구기대책，진일보제고호리기록질량。
Objective To observe the operating room nursing record sheet, carries on the analysis to the problems which appear, and Study on the management strategy, improve the quality of nursing records.Methods In January 2011 to 2014 December documented the 1648 copies of operating room nursing records, which examines the problem and classified analysis of the reasons, according to the problems and reasons of the management countermeasures.Results Through the inspection of operating room nursing records, which mainly exists project to fill in incomplete, record the contents of the error, language is not accurate, on behalf of the signature of leakage (signature), writing non-standard problems, and analysis the reason to study the corresponding countermeasures. Conclusion:Operating room nursing records both for patients and for the hospital, to clinical treatment or legal effect, have a vital role and the significance, at present operating room nursing records still some deficiencies and problems, need to explore the reasons, analysis and research the countermeasures to further improve nursing quality records.