当院における看護記録改善の取り組み～カルテ開示に向けて記録記載基準を作成して～

概要

論文の詳細を見る
The principle of informed consent is becoming increasingly important for patients in Japan. A system of disclosure of patients' charts was started in our hospital in November 1999. In order to try to improve the quality of nursing records, a manual for nursing records was made for nurses in our hospital, and the usefulness of this manual for improving nursing records was tested. The use of this manual resulted in improvements in mechanical inspections and records of patients' courses, but there were no improvements in other items of nursing records. It was realized that an overall improvement in nursing records could not be achieved without an improvement in the quality of nursing itself. To resolve this underly-ing problem, career development and improvement to the current system of guidance are needed.
2001-12-01