CAJ | 학술논문

目的：通过规范护理文件资料管理，提高护士工作质量和效率，提升优质护理服务及管理水平。方法结合ISO9001质量管理体系认证标准，建立文件资料管理框架，按行政管理、业务管理、护理安全管理、服务对象评议、护理科研和教学、护理文化信息与活动六大类文件资料，分别建立目录、进行编号、归档保存。结果文件资料控制程序和方法的建立应用，方便护理人员对文件资料的使用、查询、追溯和保管。结论科学化、规范化的管理，使护理文件资料归档管理井然有序，保障了护理管理的连续性、有效性及可追溯，对减少护患纠纷隐患，增强护患关系和谐起到积极作用。
목적：통과규범호리문건자료관리，제고호사공작질량화효솔，제승우질호리복무급관리수평。방법결합ISO9001질량관리체계인증표준，건립문건자료관리광가，안행정관리、업무관리、호리안전관리、복무대상평의、호이과연화교학、호리문화신식여활동륙대류문건자료，분별건립목록、진행편호、귀당보존。결과문건자료공제정서화방법적건립응용，방편호리인원대문건자료적사용、사순、추소화보관。결론과학화、규범화적관리，사호리문건자료귀당관리정연유서，보장료호리관리적련속성、유효성급가추소，대감소호환규분은환，증강호환관계화해기도적겁작용。
Objective To standardize nursing documentation management, enhance the level of care management. Methods Combined with ISO 9001 quality management system certiifcation standards, after ifnishing classiifcation of nursing documentation, creating a directory and archiving, establish and maintain standardized documentation controlling procedures. Results Nursing documentation can be divided into six categories as administration, business management, nursing security management, service objects council, nursing research and teaching, nursing cultural information and activities, pursuant to which we can establish a standardized, scientific documentation management framework and conduct a standardized management. Conclusion The standardized management makes the nursing documents archiving orderly, which ensures scientiifc and continuity of care management. To reduce nurse-patient disputes dangers, enhance nurse-patient relationship plays a positive role.