护理记录书写存在的主要问题及整改措施(1)
【中图分类号】：R471 【文献标识码】：C【文章编号】： 1004-597X(2007)12-0069-02【摘要】 目的:调查和分析影响护理记录书写存在的主要问题和原因，探讨护理文书书写规范的改进措施。方法:采用抽样调查方法，对永州职院附属医院2006年6月至12月的内科、外科、儿科共856份出院护理病历进行调查、统计和分析。结果:856份护理病历书写普遍存在：忽视对患者的整体评估；抄袭医生的病程记录；病情描述不准确，主观与客观的判断有混淆；书写不规范等问题。结论:加强培训是提高护理文件书写质量的基础；加强检查、督促、层层把关是保证护理文件书写质量的关键；合理安排工作，确保护理记录书写时间是提高书写质量的重要保证。
【关键词】 护理文书；书写规范；问题；整改措施
Nurses the recording writing existence the main question and reorganizes the measure
TENG Wei
【Abstract】 goal: The investigation and the analysis influence nurses the recording writing existence the main question and the reason, the discussion nurses the copy clerk writing standard the improvement measure. Method: Uses the sample investigation method, to the Vinhchau duty courtyard affiliated hospital from June, 2006 to December internal medicine department, the surgical department, department of pediatrics altogether 856 leaves the hospital nurses the medical record to carry on the investigation, the statistics and the analysis. Finally: 856 nurse the medical record writing universal existence: Neglect to patient's whole appraisal; Plagiarizes doctor's course of an illness record; Condition description plate out of true, subjective and the objective judgement has the confusion; Question and so on written not standard. Conclusion: Strengthens training is the enhancement nurses the document writing quality the foundation; Strengthens the inspection, the supervision, checks at each level is the guarantee nurses the document writing quality the key; The reasonable job placement, guarantees nurses the recording writing time is improves the written quality the important guarantee. ......
您现在查看是摘要页，全文长 4782 字符。