中小医院护理档案法律教育的效果分析

Q3 Nursing
Taehee Do, Hee-Soon Kim
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引用次数: 0

摘要

护理记录提供了对患者护理和治疗的描述,提供了一种监测进展和发展临床病史的方法。它们通过促进治疗和支持来实现护理的连续性[1]。它们是医护人员的官方沟通工具,也是患者护理的组成部分,为患者提供护理证据[2]。护理记录也被用作医疗决策、统计分析、研究、教育和保险索赔的基础数据[3]。因此,护士有责任维护他们提供的护理的准确记录,如果信息不完整和不准确,护士也有责任[4]。随着电子医疗记录的使用越来越广泛,护理记录也从纸质格式过渡到电子格式。电子护理记录(ENRs)的扩展提高了质量、完整性和准确性。此外,电子护理记录允许护士花更多的时间护理患者,因为编写护理记录所需的时间更少[2]。另一方面,一项研究批评说,ENR往往不能反映个别患者的个人护理,因为记录包含重复的、标准化的文本。这威胁到患者的安全,暴露出ENRs的负面影响[2,5]。Lee[6]报告称,护理记录在ENRs中的准确性仅为61.9%。Kang[7]发现,虽然94.9%的ENRs包含有关患者状况和状态的信息,但只有65.3%记录了为患者提供的护理服务。书写护理记录的障碍有几个原始文章ISSN 1225-9578 e-ISSN 2093-7814https://doi.org/10.5977/jkasne.2021.27.2.152JKASNE第27卷第2期,152-1622021年5月
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Effects of nursing record education focused on legal aspects at small and medium sized hospitals
Nursing records provide an account of the care and treatment given to a patient, providing a way to monitor progress and develop clinical histories. They allow for continuity of care by facilitating treatment and support [1]. They are an official communication tool for medical staff and an integral part of patient care, providing evidence of care for patients [2]. Nursing records are also used as basic data for healthcare policymaking, statistical analysis, research, education, and insurance claims [3]. Therefore, nurses are responsible for maintaining accurate records of the care they provide and are accountable if information is incomplete and inaccurate [4]. As electronic medical records are becoming more widely used, nursing records are also transitioning from paper to electronic formats. The expansion of electronic nursing records (ENRs) promotes better quality, completeness, and accuracy. Furthermore, electronic nursing records have allowed nurses to spend more time nursing patients since less time is required to write nursing records [2]. On the other hand, a study criticized that ENRs often fail to reflect individual patients’ personal nursing care because the records contain repetitive, standardized text. This threatens patient safety, revealing the negative side of ENRs [2,5]. Lee [6] reported that nursing records’ accuracy in ENRs was only 61.9%. Kang [7] found that while 94.9% of ENRs contained information about patients’ conditions and status, only 65.3% recorded nursing services provided to patients. The obstacles to writing nursing records are having several ORIGINAL ARTICLE ISSN 1225-9578 e-ISSN 2093-7814 https://doi.org/10.5977/jkasne.2021.27.2.152 JKASNE Vol.27 No.2, 152-162, May, 2021
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来源期刊
CiteScore
1.40
自引率
0.00%
发文量
29
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