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目的:探究消化内科临床护理记录中的常见问题,并提出有针对性的管理措施,提高护理记录质量。方法:随机抽取浙江省舟山医院2014年5~8月消化内科出院的70例患者临床资料作为对照组,对该组患者护理记录中出现的常见问题进行总结分析。在以后护理记录工作中制定并实施有效的管理措施,将2015年1~4月浙江省舟山医院采取措施之后,消化内科出院的70例患者临床资料作为观察组。对消化内科两组患者护理记录中存在的问题进行比较分析。结果:消化内科护理记录中存在的常见问题主要包括:护理记录不全面、医嘱内容与护理记录不相符、护理记录衔接不完整、护理记录前后矛盾以及护理记录不完整或经修改。在采取措施之后,观察组消化内科护理记录中出现的问题,明显比对照组要少(P<0.05)。结论:对消化内科护理记录中存在的问题,及时采取有效管理措施,确保护理记录的准确、及时、完整、真实、客观。
Objective: To explore the common problems in the clinical nursing records of digestive diseases and to propose targeted management measures to improve the nursing record quality. Methods: The clinical data of 70 patients discharged from Department of Gastroenterology, Zhoushan Hospital of Zhejiang Province from May to August 2014 were randomly selected as the control group, and the common problems in nursing record of this group were analyzed. In the future nursing record work to develop and implement effective management measures, from January 2015 to April Zhoushan Hospital in Zhejiang Province to take measures, the clinical data of 70 patients discharged from the Department of Gastroenterology as the observation group. The two groups of patients in the Department of Gastroenterology nursing problems in the comparative analysis. Results: The common problems in the nursing records of digestive diseases mainly include incomplete nursing records, incompatibility of medical prescriptions with nursing records, incomplete linking of nursing records, inconsistencies in nursing records and incomplete or modified nursing records. After taking the measures, the problems appearing in the digestive medical nursing records in the observation group were significantly less than those in the control group (P <0.05). Conclusion: The effective management measures should be taken in time to ensure that the nursing records are accurate, timely, complete, truthful and objective to the problems existing in the nursing records of the digestive system.