【摘要】 目的探讨《医疗事故处理条例》实施后,改进护理记录的方法。方法依据《福建省病历书写规范》(2003年修订版),针对原来护理记录存在的问题,结合我院实际,制订了包括取消多种记录单改为单一护理记录、将所有记录直接在护理记录单上体现的制度,同时规范护理记录的书写。结果改进后的护理记录不但减轻了护士的工作量,而且提高了护理人员的法律意识,使记录内容更加全面,有利于医疗纠纷的举证和提高护理质量。结论改进后的护理记录更科学,有利于护理记录资料的保管和利用。更多还原

【Abstract】 Objective To explore the improvement measures of nursing records after the implementation of "regulations for medical accidents".Methods According to the "writing standards of medical documentation in Fujian Province"(revised edition in 2003) and the actuality of our hospital,and aimed at the problems in nursing records,we integrated the different nursing records sheets into one nursing records sheet,and standardized the writing of nursing records.Results The reformed nursing records sheet not only relieved nurses’ workload,but also improved nurses’ legal awareness.It made nursing records to be more complete,which was beneficial to the quotation in medical disputes and the improvement of quality of nursing.Conclusion The reformed nursing records sheet was more scientific and was beneficial to reserve and utilize.更多还原