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护理记录中存在的问题及应对措施
引用本文:黑熙胜.护理记录中存在的问题及应对措施[J].大理学院学报,2012,11(3):67-69.
作者姓名:黑熙胜
作者单位:大理学院大理附属医院,云南大理,671000
摘    要:目的:探讨护理记录中存在的问题及应对措施。方法:对存在问题进行客观分析,增强法律意识,明确护理记录书写的重要性。结果:护理记录中存在的问题依次为:①医护记录不一致;②记录简单不准确,重点不突出,内容缺乏连续性等;③护理记录前后矛盾。结论:护士在不断提高专业技术水平的同时,还应增强法律意识,提高综合素质。

关 键 词:护理记录  问题  应对措施

Problems and Countermeasures in the Nursing Records
HEI Xisheng.Problems and Countermeasures in the Nursing Records[J].Journal of Dali University,2012,11(3):67-69.
Authors:HEI Xisheng
Institution:HEI Xisheng(Dali Affiliated Hospital of Dali University,Dali,Yunnan 671000,China)
Abstract:Objective: To explore problems in the nursing records and its countermeasures.Methods: Analyze these problems;enhance the legal awareness;impress on nurses the importance of keeping accurate records.Results: The problems in the nursing records were as follows: inconsistent recording,inaccurate recording,discontinuity of the content,no important points.Conclusion: The nurse should improve their comprehensive quality when enhancing professional capability.
Keywords:nursing records  problems  countermeasures
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