护理文书书写规范

护理文书书写规范 【关键词】护理是护士在进行医疗护理活动过程中对患者生命体征及病情变化的反映，各项护理措施落实情况的体现及结果的记录，在医疗事故和纠纷的处理中具有重要的法律意义。国务院《医疗事故处理条例》第十条规定:护理有关记录是患者有权复印或复制的病历资料。遵循卫生部、国家中医药管理局下发的《病历书写基本规范(试行)》和《医疗机构病历管理规定》的要求，护理文书记录应当客观、真实、准确、及时、完整。这不是一蹴而就的工夫，作为新上岗护士更是一个不断学习、逐步完善的过程。现院无为县人民医院护理部2006年新上岗护士书写的护理记录缺陷进行分析，并提出相应对策。 [摘要] 目的:提高护理文书书写质量，保证护理记录的真实性、客观性、科学性。方法:通过对在架病历的检查，对查出问题的原因进行分析，针对发生问题的原因采取相应对策:通过学习，提高全科护士素质，强化护士法制观念;组织护理文书书写规范的讲课和培训，针对问题进行指导、要求护士掌握护理文书书写的规范性、重要性;加强护理文书书写检查与质量控制，对护理文书书写中存在的问题，及时反馈给护士，督促改进，并与经济挂钩。结果:有效地提高了护理文书的书写质量，基本达到书写规范要求。结论:通过分析护理文书书写中产生问题的原因，有针对性地采取措施，使问题逐步得到解决，提高了护理文书书写质量，有效减少了因书写中出现失误而导致的护理纠纷。 [关键词] 护理文书;常见缺陷;原因分析;对策 [中图分类号] R47[文献标识码]C [文章编号]1673-7210(2008)09(c)-148-02 护理文书是病案资料的重要组成部分，既可反映患者的病情变化与治疗情况，又为日后医疗纠纷提供直接证据[1]。因此，护理记录应及时、客观、真实地反映对患者的护理过程和病情转归情况[2]。为进一步提高护理文书书写质量，防范医疗护理纠纷，我科通过护士长对在架病历的抽查，查对患者，分析缺陷原因，提出对策，提高了护理文书书写质量。现报道如下: 1资料与方法 2006年1,6月我科共随机抽查在架和出院病历180份，其中，一级护理病历50份，二级护理病历130份。按照《重庆市医疗文书书写规范》、《护理学基础》及整体护理的要求，以及时、准确、完整、简要、清晰为原则，以诊疗护理规范、常规作为检查的，在检查or a single tree should be fully in accordance with design drawings to locate, the allowed deviation is 3cm. Group tree planting: shall conform to the design, where the permissible deviations 50cm. Group tree planting site distribution plant: according to general principles of landscape design for 3, 5, 7 for distribution plant, the tree height should be marked on the Center piles. F, tree array of fixed line, must be correct, its line of vertical and horizontal positioning deviation does not exceed 1cm. ? planting holes (pits) excavation. A, planting holes before digging, should take the initiative to understand and hidden laying of underground pipeline to developers and ease of construction. B, point line of the planting hole, slot requirements: (1) the planting hole, slot fixed lines, the design drawings requirements, must be accurate, mark clear. (2) the size of the planting hole, slot, ball diameter according to root, soil and soil conditions may be. Hole must be dug under the vertical, equal to the head at the end, its specification should meet the requirements in the following table: c, planting hole (pit) mining of quality, has a greater impact on plant growth after. In addition to the design and location, according to roots or mud-ball size, soil conditions to determine the point size (should be larger than the root disk, or mud pie 0.25~0.5 m), according to the tree root category to determine points (pit) depth (generally greater root length or thickness of the mud pie 0.2~0.4 meters deep). D, hand-digging planting holes (pits). In fixed-point mark the Center to provide pit (hole) diameter circle on the ground, vertically downward along the circle around the mining to a defined depth. Then pit dug at the end of pine, smoothed. Exposed roots planted seedlings of the pit (point) end of dig in Central make a small mound, Eli root stretch. E, planting soil texture must be loose, protecting water and soil 过程中及时纠错反馈，并利用晨会、护士例会、讲座等机会，分析、反馈护理文书中存在缺陷的原因，提出护理干预对策，有效地提高了护理文书书写水平，避免了医疗风险。 2护理文书缺陷的表现 笔者将护理文书书写中的常见缺陷分析如下: 2.1体温单 眉栏项目填写不全，体温、脉搏、呼吸未记录或时间记录不准确，与医疗记录不一致;患者请假外出未记录，虚填体温、脉搏、呼吸;漏写入院、出院、转入转出、死亡时间;未记录血压、体重;物理降温后无记录显示;短绌脉患者心率和脉率没有同时记录或记录与病情不符;危重患者出入量未统计在体温单上。 2.2医嘱单 医嘱单分为长期医嘱单和临时医嘱单，常见缺陷表现为护士甲代替护士乙签字、漏签字，医嘱单漏填药物过敏试验结果，医生开具医嘱时间与护士执行时间不符。 2.3护理单 常见缺陷表现为缺项、护理计划不全面、护理措施不准确、不具体、护理计划的排序未按照马斯洛需要层次论排列优先顺序、护理计划与病情不符。 2.4护理记录 护理记录分为一般患者护理记录和危重患者护理记录，是住院患者医疗文件记录的一个重要组成部分，它记载了患者治疗及护理的全过程，反映了患者病情的演变，具有法律效力，是重要的法律资料。因此，护理记录的客观、准确、及时、全面是十分重要的。常见缺陷有: 2.4.1缺乏客观性，护理记录不能完全如实地记录护理行为，准确反映病情变化护理记录内容没有突出护理专业的特点，多数护士记录的内容为患者的病情以及医嘱的内容，这一方面造成与医疗内容重复，另一方面护理措施实施后，护理效果及观察到的病情在护理记录中未完全如实地记录，护理记录不能准确地描述护理行为。例如，在对一位肺心病患者的记录中，有多处记录患者病情、用药情况以及注意预防压疮，而护士采取了哪些护理措施以及or a single tree should be fully in accordance with design drawings to locate, the allowed deviation is 3cm. Group tree planting: shall conform to the design, where the permissible deviations 50cm. Group tree planting site distribution plant: according to general principles of landscape design for 3, 5, 7 for distribution plant, the tree height should be marked on the Center piles. F, tree array of fixed line, must be correct, its line of vertical and horizontal positioning deviation does not exceed 1cm. ? planting holes (pits) excavation. A, planting holes before digging, should take the initiative to understand and hidden laying of underground pipeline to developers and ease of construction. B, point line of the planting hole, slot requirements: (1) the planting hole, slot fixed lines, the design drawings requirements, must be accurate, mark clear. (2) the size of the planting hole, slot, ball diameter according to root, soil and soil conditions may be. Hole must be dug under the vertical, equal to the head at the end, its specification should meet the requirements in the following table: c, planting hole (pit) mining of quality, has a greater impact on plant growth after. In addition to the design and location, according to roots or mud-ball size, soil conditions to determine the point size (should be larger than the root disk, or mud pie 0.25~0.5 m), according to the tree root category to determine points (pit) depth (generally greater root length or thickness of the mud pie 0.2~0.4 meters deep). D, hand-digging planting holes (pits). In fixed-point mark the Center to provide pit (hole) diameter circle on the ground, vertically downward along the circle around the mining to a defined depth. Then pit dug at the end of pine, smoothed. Exposed roots planted seedlings of the pit (point) end of dig in Central make a small mound, Eli root stretch. E, planting soil texture must be loose, protecting water and soil 如何预防压疮则均无文字记录。 2.4.2缺乏准确性，没有体现因人施护和因需施护相同专科的护理记录内容千篇一律，无个体差异，记录没有针对性，不能反应出患者的个体特征。如同为糖尿患者，但对于初次患糖尿病和长期患糖尿病的护理则不同，健康教育也不相同，患者应掌握的技能也不一样。对于初患糖尿病的患者，主要是要学会如何注射胰岛素，如何配合医生用药，学会一些预防感染、发生低血糖时的自救方法;而对于长期患糖尿病的患者则更偏重于饮食和体育运动的指导，但这些在护理记录中常常未体现出来，即只体现出因病施护，而没有体现出因人施护和因需施护。 2.4.3缺乏及时性，漏记现象时有发生部分护士缺乏随时记录的意识，法律意识淡漠，护理记录简单化，临时病情变化的护理记录不全和未作记录，只是机械地按照有关规定记录。对于临时性的病情观察、采取的护理措施及护理效果记录不全或漏记，中、夜班出现此现象较多。 2.4.4缺乏连续性，不能反映护理连续动态过程护理记录是住院病历的重要组成部分，它记录着患者从入院到出院的所有病情变化、治疗、护理措施，应为一个连续性过程，但由于护理记录为阶段性记录，多数护士只记录某一天、某一时段的病情及护理措施，这种护理记录不能完全体现连续、动态的护理过程。护理记录要体现出护理的连续性，特别是上一班次患者采取治疗和护理措施后在下一班次出现结果时，下一班要准确记录患者的反应及变化过程，有时需要连续几个班次记录，而多数护士只遵照规定的护理记录频率，没有根据具体情况连续记录，甚至凭主观想象记录而出现前后不连贯，甚至矛盾的情况。 2.4.5缺乏整体性，前后不连贯，甚至矛盾护理记录与医生病历记载的分离性缺陷，护理记录逻辑性差，如在体温单体重栏内记录“卧床”，护理记录中患者活动情况“自如”。个别护理计划内容未在护理记录中体现，患者的心理、情绪变化、健康教育等内容未在护理记录中体现。如1例慢性肾盂肾炎患者，因病情反复发作，产生了悲观情绪，流露出轻生念头，护理人员发现后，及时给予心理疏导，解除思想顾虑，但以上内容未体现在护理记录中。 2.5输液、注射执行观察记录单 or a single tree should be fully in accordance with design drawings to locate, the allowed deviation is 3cm. Group tree planting: shall conform to the design, where the permissible deviations 50cm. Group tree planting site distribution plant: according to general principles of landscape design for 3, 5, 7 for distribution plant, the tree height should be marked on the Center piles. F, tree array of fixed line, must be correct, its line of vertical and horizontal positioning deviation does not exceed 1cm. ? planting holes (pits) excavation. A, planting holes before digging, should take the initiative to understand and hidden laying of underground pipeline to developers and ease of construction. B, point line of the planting hole, slot requirements: (1) the planting hole, slot fixed lines, the design drawings requirements, must be accurate, mark clear. (2) the size of the planting hole, slot, ball diameter according to root, soil and soil conditions may be. Hole must be dug under the vertical, equal to the head at the end, its specification should meet the requirements in the following table: c, planting hole (pit) mining of quality, has a greater impact on plant growth after. In addition to the design and location, according to roots or mud-ball size, soil conditions to determine the point size (should be larger than the root disk, or mud pie 0.25~0.5 m), according to the tree root category to determine points (pit) depth (generally greater root length or thickness of the mud pie 0.2~0.4 meters deep). D, hand-digging planting holes (pits). In fixed-point mark the Center to provide pit (hole) diameter circle on the ground, vertically downward along the circle around the mining to a defined depth. Then pit dug at the end of pine, smoothed. Exposed roots planted seedlings of the pit (point) end of dig in Central make a small mound, Eli root stretch. E, planting soil texture must be loose, protecting water and soil 常见缺陷有:静脉输液滴数与医嘱不符，护士签字潦草，缺项。 3讨论 3.1缺陷分析 主要表现为:?部分护士的法律意识不强，缺乏自我保护意识。记录时不认真，涂改、代写、代签名，转抄医嘱后忘记签名，执行医嘱后或发现患者病情变化时不及时记录[2]。?护士对护理记录书写的重要性认识不足。在临床护理工作中，护士往往只重视解决患者的实际问题，而不重视护理文件的记录，出现错记、记录不全等现象[2]。?个别护士工作责任心不强。在对患者病情进行治疗、护理中，观察不认真、不仔细，故记录不能客观地反映患者的情况。?护士综合素质偏低。我国的护理教育长期以来以中专教育为主，特别是近年来，护士的来源以职业中专毕业者居多，护士的语言表达能力和综合素质较差，其理论水平亦不能满足临床护理的服务需求，对病情观察不到位，不能很好地收集病情资料，记录不及时，这些造成护士在书写护理记录时抓不住重点，或只重视患者的精神、饮食，遵医嘱治疗而无健康教育内容，记录缺乏专科特点及患者个性化特点。?护理人员不足、工作量大。护士处于繁忙的护理工作中，各种记录又要占用护士大量的时间及精力，使护士身心疲惫感加重，而且重复记录越多，越容易出现失误。?患者及家属对护士不信任。一直以来，护士的从属地位使人们认为护士只会听医生的医嘱，只会打针、输液，病情不应该对护士讲述，这些致使护士在书写护理记录中也存在一些困难。 3.2对策 3.2.1增强护理人员法律意识，提高护理记录质量《医疗事故处理条例》实施后，护士各方面的素质迫切需要提高，我科积极鼓励护士参加各种形式的学习，提高护士理论水平，同时加强护士法律知识的学习，增强法制观念，帮助护士分析护理差错、事故与护理记录的关系，使护士充分认识到护理记录在医疗纠纷举证中的重要作用，树立执行护理记录的正确意识:护理记录既是记录患者病情及治疗护理措施、为医生提供诊疗的文字资料，也是在出现护理纠纷时保护自己的重要法律依据[3,4]。 3.2.2加强对护士的培训，提高整体素质鼓励护理人员参加多种形式的学习，提高护士对护or a single tree should be fully in accordance with design drawings to locate, the allowed deviation is 3cm. Group tree planting: shall conform to the design, where the permissible deviations 50cm. Group tree planting site distribution plant: according to general principles of landscape design for 3, 5, 7 for distribution plant, the tree height should be marked on the Center piles. F, tree array of fixed line, must be correct, its line of vertical and horizontal positioning deviation does not exceed 1cm. ? planting holes (pits) excavation. A, planting holes before digging, should take the initiative to understand and hidden laying of underground pipeline to developers and ease of construction. B, point line of the planting hole, slot requirements: (1) the planting hole, slot fixed lines, the design drawings requirements, must be accurate, mark clear. (2) the size of the planting hole, slot, ball diameter according to root, soil and soil conditions may be. Hole must be dug under the vertical, equal to the head at the end, its specification should meet the requirements in the following table: c, planting hole (pit) mining of quality, has a greater impact on plant growth after. In addition to the design and location, according to roots or mud-ball size, soil conditions to determine the point size (should be larger than the root disk, or mud pie 0.25~0.5 m), according to the tree root category to determine points (pit) depth (generally greater root length or thickness of the mud pie 0.2~0.4 meters deep). D, hand-digging planting holes (pits). In fixed-point mark the Center to provide pit (hole) diameter circle on the ground, vertically downward along the circle around the mining to a defined depth. Then pit dug at the end of pine, smoothed. Exposed roots planted seedlings of the pit (point) end of dig in Central make a small mound, Eli root stretch. E, planting soil texture must be loose, protecting water and soil 理记录重要性的认识、工作责任心及工作水平，转变服务理念，变被动工作为主动工作。严格规范医疗护理行为,做到做、说、写一致。护士不但要严格遵守而且要认真执行与落实一切护理规章和操作规程,为患者提供一流的护理服务,重视对患者进行健康教育及有效沟通,同时也要及时、完整、认真地完成一切护理记录，使护理文书记录能够达到规范化、证据化，使之成为重要的法律依据，从而达到自我保护的目的。 3.2.3科室内多次组织护理文书书写的讲课针对护士在书写中存在的问题进行分析，提出解决方法，并将书写规范的护理记录在科室内进行讲评，促进学习，提高护理文书的书写能力。在护士业务学习、业务查房、每月质量分析时把护理记录内容列在其中，并相互交流书写护理记录的经验，同时让资深护士检查指导资历较浅的护士书写护理记录。 3.2.4加强护理记录书写质量管理完善科室护士长、责任组长两级护理质控人员对护理记录书写质量检查，分层负责，层层把关，做好实施环节与终末质量监控的有机结合。 3.2.5建立良好的护患关系护士掌握良好的沟通技巧，加强与患者的沟通，了解并切实解决患者的需求，取得患者的信任，掌握更多的第一手资料，做到因人施护、因病施护，对作好护理记录都有非常重要的作用。 3.2.6依据标准，不定期抽查依此质量评价标准，护士长和责任组长对住院和出院病历采取定期检查和不定期抽查，将检查重点放在护士是否及时、准确观察病情上，护理措施是否科学、合理、可行，记录是否及时、客观、真实等质量方面。 通过采取提高护士整体素质、强化护士法制观念、提高护士书写的基本功、加强护患沟通、提高患者对护士的信任度、加强护理记录书写质量的控制与管理等对策后，我科护理文书书写质量得到大幅度提高，护理文书书写合格率达到95.3%。 [参考文献] [1]卫生部医政司.医疗事故处理条律[M].北京:中国法制出版社,2002.6. [2]胡兴媛,蔡文焕,李华云.对护理文书书写中存在问题原因分析及对策[J].中华现代护理学杂志,2006,3(16):1495-1496. [3]颜坤.护理病历中存在的问题及防范对策[J].中国医药导报,2008,5(14):149-150. [4]阿达来提?买买提.护理文书书写存在的问题及对策[J].中国现代医生,2008,46(6):127. or a single tree should be fully in accordance with design drawings to locate, the allowed deviation is 3cm. Group tree planting: shall conform to the design, where the permissible deviations 50cm. Group tree planting site distribution plant: according to general principles of landscape design for 3, 5, 7 for distribution plant, the tree height should be marked on the Center piles. F, tree array of fixed line, must be correct, its line of vertical and horizontal positioning deviation does not exceed 1cm. ? planting holes (pits) excavation. A, planting holes before digging, should take the initiative to understand and hidden laying of underground pipeline to developers and ease of construction. B, point line of the planting hole, slot requirements: (1) the planting hole, slot fixed lines, the design drawings requirements, must be accurate, mark clear. (2) the size of the planting hole, slot, ball diameter according to root, soil and soil conditions may be. Hole must be dug under the vertical, equal to the head at the end, its specification should meet the requirements in the following table: c, planting hole (pit) mining of quality, has a greater impact on plant growth after. In addition to the design and location, according to roots or mud-ball size, soil conditions to determine the point size (should be larger than the root disk, or mud pie 0.25~0.5 m), according to the tree root category to determine points (pit) depth (generally greater root length or thickness of the mud pie 0.2~0.4 meters deep). D, hand-digging planting holes (pits). In fixed-point mark the Center to provide pit (hole) diameter circle on the ground, vertically downward along the circle around the mining to a defined depth. Then pit dug at the end of pine, smoothed. Exposed roots planted seedlings of the pit (point) end of dig in Central make a small mound, Eli root stretch. E, planting soil texture must be loose, protecting water and soil