[1]张致萍,刘秀芳.护理记录中潜在的法律风险及对策[J].西部中医药,2018,31(11):118-120.
　ZHANG Zhiping,LIU Xiufang.On the Potential Legal Risk in Nursing Records and the Countermeasures[J].Western Journal of Traditional Chinese Medicine,2018,31(11):118-120.
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护理记录中潜在的法律风险及对策()
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《西部中医药》[ISSN:2096-9600/CN:62-1204/R]

卷:
31
期数:
2018年11期
页码:
118-120
栏目:
出版日期:
2018-11-15

文章信息/Info

Title:
On the Potential Legal Risk in Nursing Records and the Countermeasures
文章编号:
1004-6852(2018)11-0118-03
作者:
张致萍，刘秀芳
甘肃省中医院，甘肃 兰州 730050
Author(s):
ZHANG Zhiping, LIU Xiufang
Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou 730050, China
关键词:
护理记录; 法律风险; 对策
Keywords:
nursing records;  legal risk;  countermeasures
分类号:
R471
文献标志码:
B
摘要:
目的：探讨护理记录中潜在的法律风险及对策，提高护理质量，减少差错事故及护理纠纷发生率。方法：将某医院2014年8月至2016年8月收治的2 571例住院患者作为研究对象，利用回顾性方法对患者的住院病历资料中潜在的法律问题展开分析。结果：在所选取的2 571份患者的临床护理记录中，共出现潜在法律问题24例次，依次为涂改及缺空现象9例次，占37.5%；记录不真实、不及时、不全面5例次，占20.8%；医嘱与护士执行时间不吻合3例次，占12.5%；医、护记录不吻合3例次，占12.5%；护理记录之间不衔接2例次，占8.3%；护理记录不具体、漏记重要内容1例次，占4.2%；输液滴速与输液完的时间不吻合1例次，占4.2%。结论：进行护理记录时要加强对护理人员的法制教育，强化法律意识；增强医护沟通，保障医护记录的一致性；强化专业理论学习，保障护理记录的及时性与准确性；开展护理记录质量管理三级监控措施，提高护理文书书写质量要求，降低护患纠纷发生率。
Abstract:
Objective: To raise nursing quality, reduce error and accidents and the incidence of nursing disputes by discussing the potential legal risk in the nursing records and the countermeasures. Methods: All 2 571 inpatients who were admitted from August, 2014 to August, 2016 into our hospital were chosen as the object of study, the potential legal issues in the patients' inpatient medical records were analyzed using retrospective method. Results: In clinical nursing records of 2 571 patients who were selected, there were 24 cases showing potentital legal issues, they were nine cases of altering and vacancy, which held 37.5%; five cases of the records which were not true, timely and complete, and they occupied 20.8%; three cases in which medical advices were not identical to the nurses' execution time, and 12.5%; three cases that medical records couldn't fit nursing records, and 12.5%; two cases that nursing records couldn't connected and they occupied 8.3%; one case of nursing records that wasn't concrete and important contents were lacked, which held 4.2%; one case that infusion velocity couldn't fit the time of finishing the infusion, and it held 4.2%. Conclusion: When performing nursing records, we should enhance legal education to nursing staffs, and their legal sense, strengthen doctor-nurse communication, ensure the uniformity in medical and nursing records, intensify professional theorectical study, guarantee the timeliness and accuracy of nursing records, launching three-level monitoring measures of nursing records quality management, raise quality requirements for writting nursing documents and decrease the incidence of nurse-patients disputes.

备注/Memo

备注/Memo:
收稿日期：2018-02-20 作者简介：张致萍(1975—)，女，主管护师。研究方向：骨科疾病的护理。
更新日期/Last Update: 2018-11-15