J4 ›› 2012, Vol. 11 ›› Issue (3): 67-69.
目的:探讨护理记录中存在的问题及应对措施。方法:对存在问题进行客观分析,增强法律意识,明确护理记录书写的重要性。结果:护理记录中存在的问题依次为:淤医护记录不一致;于记录简单不准确,重点不突出,内容缺乏连续性等;盂护理记录前后矛盾。结论:护士在不断提高专业技术水平的同时,还应增强法律意识,提高综合素质。
Objective: To explore problems in the nursing records and its countermeasures. Methods: Analyze these problems;enhance the legal awareness; impress on nurses the importance of keeping accurate records. Results: The problems in the nursing records were as follows: inconsistent recording, inaccurate recording, discontinuity of the content, no important points. Conclusion:The nurse should improve their comprehensive quality when enhancing professional capability.