CAJ | 학술논문

目的：分析临床护理工作中护理文书书写缺陷，探讨运行质控和终末质控临床意义。方法随机抽取本院病历护理文书部分360份，分析其中存在的问题。结果运用运行质控和终末质控，提高了护理文书的书写质量。结论实时和及时分析护理文书中存在的问题，提高护理文书质量，降低医患纠纷。
목적：분석림상호리공작중호리문서서사결함，탐토운행질공화종말질공림상의의。방법수궤추취본원병력호리문서부분360빈，분석기중존재적문제。결과운용운행질공화종말질공，제고료호리문서적서사질량。결론실시화급시분석호리문서중존재적문제，제고호리문서질량，강저의환규분。
Objective In order to analyze the clinical nursing work of nursing document writing defects and discuss on the significance of operation quality control and final quality control of clinical . Methods Through the random sample of hospital recordsof nursing document part 360,and analyze of the existing problems. Results Has shown that:using operating control and terminal quality can analysis of the problems in nursing records in time, improve the quality of nursing records and reduce medical disputes. Conclusion There real-time and timely analysis of the problems in nursing records, to improve the quality of nursing records, reduce medical disputes.