J4 ›› 2012, Vol. 11 ›› Issue (3): 67-69.

• 临床医学 • 上一篇    下一篇

护理记录中存在的问题及应对措施

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。   

  1. 大理学院大理附属医院,云南大理 671000
  • 收稿日期:2011-11-30 修回日期:2012-01-16 出版日期:2012-03-15 发布日期:2012-03-15
  • 作者简介:黑熙胜,主管护师,主要从事普通外科护理研究.

Problems and Countermeasures in the Nursing Records

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.   

  1. Dali Affiliated Hospital of Dali University, Dali, Yunnan 671000, China
  • Received:2011-11-30 Revised:2012-01-16 Online:2012-03-15 Published:2012-03-15

摘要:

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。

关键词: 护理记录, 问题, 应对措施

Abstract:

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.

Key words: nursing records, problems, countermeasures

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