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目的了解体温单的描、记情况,认识体温单在病案质量及医疗纠纷举证责任的重要作用。方法依据《重庆市护理文件书写规范》标准,检查2008年10月-2009年3月的1200份病案,找出存在的法律性问题,并提出改进措施。结果体温单上存在的法律性问题比较突出,体温单上缺陷项为15%-36%。结论增强法律意识、证据意识和质量意识,正确描、记体温单上的项目,可以提高病案质量及诉讼时举证有力有据。
Objective To understand the description of body temperature, record the situation and understand the important role of body temperature in the medical record quality and medical dispute burden of proof. Methods According to the standard of “Nursing Document Writing in Chongqing”, 1,200 medical records from October 2008 to March 2009 were examined to find out the existing legal problems and put forward improvement measures. Results There were more legal problems on the list of body temperature, and the defect on the body temperature list was 15% -36%. Conclusion Enhancing legal consciousness, evidence-based awareness and quality awareness, correctly describing items on the questionnaire can improve the quality of the medical record and provide strong evidence for evidence when litigation.