【摘要】 护理记录是护士根据医嘱和病情对患者住院期间护理过程的客观记录。护理重复记录主要表现为与医疗病程记录重复,与医嘱单、体温单、血压单重复等,由此造成重复劳动,既增加了护士工作压力,又容易出现记录与实际不符,更易成为引发医患纠纷的隐患。因此,应加强基层医院护士法律知识培训,提高护士执业风险意识,制定既符合医疗、护理文书书写规范,又方便临床实施的具体规定,积极组织相关知识的培训,提高护士书写能力。更多还原

【Abstract】 Nursing record was a transcript of nursing process for inpatients according to medical order and patient’s condition. Some nursing record duplicated the record of medical record, medial order list, temperature list and blood pressure list. The duplication increased nurse’s workload, might not accord with facts, and might cause medical disputes. So, it is important to strengthen legal knowledge training to increase the risk consciousness of nurses working in grass-root hospitals, formulate writing standard which accord with ‘medical and nursing record standard’ and was convenient for clinical use, and train nurses to increase their writing ability.更多还原