Study For The Writing Quality Of Nursin Gdocuments-Illustrated By The Case Of 10 General Hospitals In Harbin

With the rapid development of medical science, the deepening of reform of health programs, professional medical practitioners law promulgated, the truthfulness of medical record, the standardization is put forward higher requirements. Medical record quality is the lifeline of a hospital, it holds an important place in the hospital. It has the law, in the medical dispute is one of the best proof materials. As an important part of the medical record in nursing document, is the raw data of the nursing staff is the most precious, is one of the first data of clinical disease, also is the archives of medical science. It can be objective, complete and continuous record after the patient’s condition change and the diagnosis and treatment, teaching, scientific research and medical disputes, for the future management of the hospital to provide the most reliable basis. It effectively safeguard the legitimate rights and interests of between doctor and patient. Therefore, the quality of nursing documents are directly related to the patient’s diagnosis and treatment quality and safety, related to the integrity and authenticity of the medical litigation evidence law. This research through to the Harbin city 10 general hospital nursing documents quality present situation investigation, find out the problems existing in the quality of nursing documents and their causes, and proposes the corresponding improvement countermeasures, the results can be for the sustainable improvement of quality of hospital nursing documents provide valuable reference.Using stratified sampling method, in Harbin municipal districts were randomly selected second and third of the five general hospitals, with its general surgery, cardiac care and nursing documents as the research object, the survey from March 2015 to September 2015 period nursing documents 909.Including surgical department 262, medical department 265 in tertiary hospitals, surgical department 178, medical department 204 in secondary hospitals. By using the methods literature method,spot field investigation and personal interviewcombined status of research. Data analysis is mainly descriptive statistics by χ2 test.The objective of hospital nursing document quality assessment show that:the average score in tertiary hospitals of surgical departments and medical departments are 97.20,97.26; surgical departments and medical departments are 97.64,98.22, in secondary hospitals. The secondary hospitals are better than the tertiary hospitals. The nursing documents do not have statistical difference.Critical care nursing records have the best quality. The main problems are:scratch, sticky, coating, the wrong date, the incomplete of content of records, illegible handwriting, the wrong records of the dynamics of blood pressure, weight.In General Hospital of Harbin City, the overall quality of nursing documents is well. However, there are some problems. The main reason of nursing documents drawback:the shortage of nurses, awareness of the law, indifferent sense of duty, nurses professional and cultural qualities to be improved, lack of health care communication, administrative supervision is not enough.