[摘要] 护理文书是病案的重要组成部分，具有法律效应，护士应按规范客观、真实、准确、及时、完整地完成护理文书记录，加强护理文书质量的关键在于环节质控。通过对运行电子护理文书质量实时有效的三级质控，分层负责，层层把关，建立长效管理机制，可有效提高运行电子护理文书的整体质量。

    [关键词] 电子护理文书；三级质控；缺陷；对策

    [中图分类号] R197.324[文献标识码] B[文章编号] 1674-4721(2014)03(c)-0154-03

    Analysis of the pediatric operation of electronic nursing records defects and countermeasures

    YANG Xiu-ling

    Department of Internal Medicine,Children′s Hospital of Jiujiang City in Jiangxi Province,Jiujiang 332000,China

    [Abstract] Nursing documents is an important part of medical records and have legal effects,therefore,the nurses should complete such documents formally,objectively,faithfully,accurately,promptly and completely.The key to improve the quality of nursing documents lies in process quality control.Through implement the three-level real-time quality control and establish a long-term management mechanism,we can effectively improve the overall quality of operation of electronic nursing records.

    [Key words] Electronic nursing records;Three-level quality control;Defect;Countermeasure

    护理文书是临床护士实施护理过程真实、客观、动态的记录 ......