CAJ | 학술논문

收集我院冠心病重症监护病房(CCU)2012年8月至2014年6月护士长在日常护理检查工作中发现的存在书写缺陷的护理病历共233份,采用访谈的方法对可能存在的原因进行分析.结果发现,护理记录缺陷主要包括:护理记录项目缺失或存在漏项情况、书写不规范、常规护理项目描述不详细、存在错别字、护理记录前后不一致、缺乏专科重点观察项目等.分析其原因可能有护理人员法律意识淡薄,对护理文书的重要性认识不足;缺乏专科护理知识;护士的工作琐碎繁忙,导致护理记录不及时,而在补充记录时很容易造成项目缺失或失真的情况;电子病历系统有待于进一步完善.提示应针对以上原因采取整改措施,包括加强护理人员法律知识、专业基础的学习,不断完善信息系统,以减少护理记录缺陷的发生.
수집아원관심병중증감호병방(CCU)2012년8월지2014년6월호사장재일상호리검사공작중발현적존재서사결함적호리병력공233빈,채용방담적방법대가능존재적원인진행분석.결과발현,호리기록결함주요포괄:호리기록항목결실혹존재루항정황、서사불규범、상규호리항목묘술불상세、존재착별자、호리기록전후불일치、결핍전과중점관찰항목등.분석기원인가능유호리인원법률의식담박,대호리문서적중요성인식불족;결핍전과호리지식;호사적공작쇄쇄번망,도치호리기록불급시,이재보충기록시흔용역조성항목결실혹실진적정황;전자병력계통유대우진일보완선.제시응침대이상원인채취정개조시,포괄가강호리인원법률지식、전업기출적학습,불단완선신식계통,이감소호리기록결함적발생.
The convenient sampling methods was used to collect nursing records with writing defects in the CCU from August 2012 to June 2014,and were interviewed to explore the possible reason.The reasons of nursing record defects mainly included the item missing,nonstandard recording,the routine nursing record not detailed,wrong character,inconsistently recording,lack of specialized subjects in the recording.The properly reasons were nurses' legal consciousness faint,lack of understanding of the importance of nursing recording,lack of the specialized nursing knowledge.Nurses' work were busy and trivial,resulting in nursing records not in time,and supplement the record was easy to cause loss or distortion of the items.Electronic medical record system needs to be further improved.Strengthening the study of legal knowledge and professional nursing foundation,perfecting the information system,can effectively control the nursing records defects in the busy nursing daily work.