— 照護管理 · MEDIUM · MCQ —
下列哪項護理師行動顯示其正確使用事故報告？
Which of the following actions by a nurse demonstrates appropriate use of incident reports?
- AIncluding the report in the client's medical record將報告放入病人病歷中
- BMentioning the report in the nursing progress notes在護理進度紀錄中提及該報告
- CDocumenting in the chart that an incident report was filed在病歷中記錄已提交事故報告
- DObjectively describing the event without expressing blame✓ 正解客觀描述事件且不表達指責
— Explanation · 中文詳解 —
事故報告（Incident Report）用於品質改善，不具法律懲罰性質。報告應客观陳述事實，避免歸咎責任或臆測。此外，事故報告屬內部行政文件，嚴禁放入病歷（Chart）或在護理紀錄中提及，以免在法律訴訟中產生不利證據。
An incident report is used for quality improvement and is not punitive in nature. The report should objectively state the facts and avoid assigning blame or speculation. Furthermore, the incident report is an internal administrative document and must not be placed in the medical record (chart) or referenced in the nursing notes, to avoid creating unfavorable evidence in legal proceedings.
✦ 台美臨床差異
兩地均嚴格要求事故報告與病歷分離，但美國對於訴訟防禦的法規標準極為嚴謹。