摘要
目的 :探讨现阶段护理病历存在的问题 ,并提出相应的对策 ,以提高护理病历书写质量 ,适应《医疗事故处理条例》的要求。方法 :抽查我院 2 0 0 3年 4月到 12月住院的出院病历 2 0 0份 ,以《广东省护理病历书写规范》为标准进行评分、分析。结果 :抽查的 2 0 0份护理病历仍存在着不利于举证倒置的缺陷。结论 :要提高护理文件的书写质量 ,就必须提高法律意识 ,加强学习 ,加强医护沟通。
Objective: Discussing the existing problems in nursing records, and providing countermeasures to improve nursing records quality and fulfill the requirement of “malpractice-handling regulations'. Method: Spot-checked 200 sets of medical records from April to December in 2003, analyzed and marked following the standards of “ Nursing record writing standard of Guangdong province'. Results: All records had the deficiency about shifting of burden of evidence. Conclusion: In order to improve the quality of nursing records, consciousness of law and communication between doctors and nurses must be improved.
出处
《中国护理管理》
2004年第4期32-34,共3页
Chinese Nursing Management
