浙江医学教育
浙江醫學教育
절강의학교육
Zhejiang Medical Education
2014年
6期
22-23,58
,共3页
祝霞君%缪小红%周瑛%李滔梅
祝霞君%繆小紅%週瑛%李滔梅
축하군%무소홍%주영%리도매
质控本%图片记录%产科护理文书%质量控制%应用
質控本%圖片記錄%產科護理文書%質量控製%應用
질공본%도편기록%산과호리문서%질량공제%응용
quality control record%picture recording%obstetric nursing documents%quality control%application
在出院病历质控的基础上，增加对在架病历质控检查，将存在问题记录在护理文书质控本，每月进行归纳总结。对存在的典型问题用手机拍摄成图，即时上传科室QQ群，并对存在问题进行分析与指导，提高产科出院病历的护理文书书写质量。
在齣院病歷質控的基礎上，增加對在架病歷質控檢查，將存在問題記錄在護理文書質控本，每月進行歸納總結。對存在的典型問題用手機拍攝成圖，即時上傳科室QQ群，併對存在問題進行分析與指導，提高產科齣院病歷的護理文書書寫質量。
재출원병력질공적기출상，증가대재가병력질공검사，장존재문제기록재호리문서질공본，매월진행귀납총결。대존재적전형문제용수궤박섭성도，즉시상전과실QQ군，병대존재문제진행분석여지도，제고산과출원병력적호리문서서사질량。
Based on medical record quality control ,we enhance the inspection of quality control of medical record in frame .The existing problems were recorded in nursing documents and summarized every month .The typical problems were recorded with mobile phone and uploaded to QQ group instantly to analyze .It can significantly improve the obstetric hospital medical record writing quality of nursing documents .
