| 死亡病历护理文书中存在问题的原因与对策 |
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| 引用本文： | 孟宪辉,赵风云,金秀琴.死亡病历护理文书中存在问题的原因与对策[J].内蒙古民族大学学报(自然科学版),2007,22(2):222-223. |
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| 作者姓名： | 孟宪辉 赵风云 金秀琴 |
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| 作者单位： | 内蒙古民族大学,附属医院,内蒙古,通辽,028000 |
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| 摘 要： | 目的：探讨死亡病历护理文件书写存在的问题及采取的对策．方法：采用实际检查方法，对325份死亡病历护理文件书写质量进行总结，分析其问题所在．结果：不合格病历56份，占所查病历总数的17．23％．结论：通过整理分析使护理人员的法律意识增强，严格按照《病历书写基本规范》认真、及时的书写护理记录，提高了病历书写质量，避免医疗纠纷。
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| 关 键 词： | 死亡病历 护理文件 |
| 文章编号： | 1671-0185（2007）02-0222-02 |
| 收稿时间： | 2006-12-10 |
| 修稿时间： | 2006年12月10 |
Reasons for and Countermeasures against Existing Problems in Nursing Records of Death Cases |
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| MENG Xian-hui,ZHAO Feng-yun,JIN Xiu-qin.Reasons for and Countermeasures against Existing Problems in Nursing Records of Death Cases[J].Journal of Inner Mongolia University for the Nationalities(Natural Sciences),2007,22(2):222-223. |
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| Authors: | MENG Xian-hui ZHAO Feng-yun JIN Xiu-qin |
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| Institution: | Affiliated Haspital, Inner Mongolia University for Nationalities, Tongliao 028000, China |
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| Abstract: | Objective:To analyze the situations about nursing records of death cases and countermeasures to be taken.Methods:Actual examination method was applied to inspect nursing records of 325 death cases and analyze the existing problems.Results:56(17.23%) nursing records were not qualified.Conclusion:The law awareness of nursing staff was strenghtened and they tended to write medical record carefully and timely according to Fundamental Standard for Writing Medical Record.The quality of medical record is improved and it's helpful to avoid medical dispute. |
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| Keywords: | Death cases Nursing record |
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