Open Access Article
International Journal of Nursing Research. 2020; 2: (6) ; 765-767 ; DOI: 10.12208/j.ijnr.20200238.
Causes and countermeasures of defects in nursing records of orthopedics of traditional Chinese medicine
中医骨科护理记录缺陷的原因与对策
作者：
朱智梅 *
云南省中医医院骨伤科 云南昆明
*通讯作者：
朱智梅,单位：云南省中医医院骨伤科 云南昆明；
发布时间: 2020-10-20 总浏览量: 759
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摘要
目的 研究中医骨科护理记录缺陷发生原因与对策。方法 本次研究开始时间为2018年3月，结束时间为2019年1月，需要选取2020份中医骨科护理记录，包括256份护理缺陷记录。需要研究人员分析中医骨科护理记录出现缺陷的原因、不同年资护理人员护理缺陷率，根据护理记录缺陷原因提出降低护理记录缺陷率的对策。结果 256份护理记录存在缺陷，其中有57份护理记录中涂改、错字，占比为22.27%，有13份医疗记录与护理记录有出入，占比为5.08%，有64份出现护理记录表格不完整，占比为25%，69份护理记录中缺少辩证施护内容，占比为26.95%，有29份无皮试结果及执行护士签名，占比为11.33%，有24份医嘱无执行护士签名，占比为9.38%。结论 中医骨科出现护理记录缺陷的原因比较多，容易造成护理差错，增加护理不良事件发生率，提升医疗纠纷发生率。需要科室将护理记录缺陷高度重视起来，加强科室护理人员培训，规范护理记录书写。
关键词： 中医骨科；护理记录缺陷；对策
Abstract
Objective: To study the causes and countermeasures of defects in orthopedic nursing records of traditional Chinese medicine. Methods: The study started in March 2018 and ended in January 2019. It is necessary to select 2020 TCM orthopedic nursing records, including 256 nursing defect records. Researchers need to analyze the causes of defects in TCM orthopedic nursing records and the nursing defect rate of nursing staff of different seniority, and propose measures to reduce the defect rate of nursing records based on the causes of defects in nursing records. Results: 256 nursing records were defective, of which 57 nursing records were altered or typo, accounting for 22.27%, 13 medical records were inconsistent with nursing records, accounting for 5.08%, and 64 nursing record forms appeared Incomplete, accounting for 25%, 69 nursing records lacking dialectical nursing content, accounting for 26.95%, 29 cases without skin test results and executing nurse signatures, accounting for 11.33%, and 24 doctor orders without execution Nurses signed, accounting for 9.38%. Conclusion : There are many reasons for the defects of nursing records in orthopedics of traditional Chinese medicine, which can easily cause nursing errors, increase the incidence of nursing adverse events, and increase the incidence of medical disputes. Departments are required to attach great importance to the defects of nursing records, strengthen the training of department nurses, and standardize the writing of nursing records.
Key words： Traditional Chinese Medicine Orthopedics; Defects in nursing records; Countermeasures
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引用本文
朱智梅, 中医骨科护理记录缺陷的原因与对策[J]. 国际护理学研究, 2020; 2: (6) : 765-767.