医学信息
醫學信息
의학신식
MEDICAL INFORMATION
2014年
23期
423-424
,共2页
护理文件%书写质量%分析%对策
護理文件%書寫質量%分析%對策
호리문건%서사질량%분석%대책
Nursing document%Writing quality%Analysis%Countermeasures
护理人员在医疗、护理活动过程中形成的文字、符号、图表等资料的总称为护理文件，是护士工作行为记录的文字材料，也是各项护理活动及病情观察的客观记录。护理文件记录是病历的重要组成部分，是患者可以复印或复制的内容之一。因此，真实、全面、准确的护理文件记录，不但可以反映护士的综合素质，还是保护护患双方合法权利的举证依据。长期以来，护理文件书写不规范、不准确的现象常临床护理工作中存在。新版病历书写规范实施后，通过对我院护理文件书写质量进行分析，为护理文件书写品质改进提供相关依据，促进临床质量改善。
護理人員在醫療、護理活動過程中形成的文字、符號、圖錶等資料的總稱為護理文件，是護士工作行為記錄的文字材料，也是各項護理活動及病情觀察的客觀記錄。護理文件記錄是病歷的重要組成部分，是患者可以複印或複製的內容之一。因此，真實、全麵、準確的護理文件記錄，不但可以反映護士的綜閤素質，還是保護護患雙方閤法權利的舉證依據。長期以來，護理文件書寫不規範、不準確的現象常臨床護理工作中存在。新版病歷書寫規範實施後，通過對我院護理文件書寫質量進行分析，為護理文件書寫品質改進提供相關依據，促進臨床質量改善。
호리인원재의료、호리활동과정중형성적문자、부호、도표등자료적총칭위호리문건，시호사공작행위기록적문자재료，야시각항호리활동급병정관찰적객관기록。호리문건기록시병력적중요조성부분，시환자가이복인혹복제적내용지일。인차，진실、전면、준학적호리문건기록，불단가이반영호사적종합소질，환시보호호환쌍방합법권리적거증의거。장기이래，호리문건서사불규범、불준학적현상상림상호리공작중존재。신판병역서사규범실시후，통과대아원호리문건서사질량진행분석，위호리문건서사품질개진제공상관의거，촉진림상질량개선。
The nursing staff in medical, nursing activities in the course of the text, symbols, graphics data col ectively referred to as the nursing documents, the nurse's job is record writing material, objective record is nursing activities and the observation of disease. The nursing records is an important part of medical records, is one of the patients can copy or duplicate content. Therefore, true, accurate, comprehensive nursing records, not only can reflect the comprehensive quality of nurses, nurse patient burden of evidence or the protection of the legitimate rights of both. For a long time, there are nonstandard nursing document, inaccurate phenomenon often in clinical nursing work. The new record writing standard is implemented, based on the analysis of writing quality of nursing documents in our hospital, and to provide evidence for nursing document writing quality improvement, promote the clinical quality improvement.
