| 规范护理文书书写标准完善护理病案质量监控 |
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| 引用本文： | 周荣慧. 规范护理文书书写标准完善护理病案质量监控[J]. 护理管理杂志, 2002, 2(6): 19-20 |
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| 作者姓名： | 周荣慧 |
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| 作者单位： | 100020,北京市朝阳医院 |
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| 摘 要： | 针对国务院《医疗事故处理条例》及相关配套文件的要求,我院制订了《北京朝阳医院护理文书书写标准》,并围绕着护理病历书写培训与质量监控等问题阐述了自己的看法与做法,指出首先应认真学习提高认识,其次修改符合实际要求的护理表格,制定具体实用的书写标准,确保有法可依,改革工作流程,确保医疗安全 .开展多层次系列培训是一项长期的系统工程,应逐步建立规范化培训方案,并完善护理病案书写质量监控体系,全面提高护理病案质量,使其真正成为法律依据和提高护理质量的有效资源.
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| 关 键 词： | 护理病案 规范化管理 培训与质量监控 |
| 修稿时间： | 2002-09-20 |
Strict standards of writing nursing documents,set up a training program and a quality control system |
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| ZHOU Ronghui. Strict standards of writing nursing documents,set up a training program and a quality control system[J]. Journal of Nursing Administration, 2002, 2(6): 19-20 |
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| Authors: | ZHOU Ronghui |
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| Affiliation: | ZHOU Ronghui |
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| Abstract: | According to the changes in conflicts and laws on medicine and nursing in China.Our nursing department has set up a set of standard on nursing documents and educated nurses how to write.Quality has also been supervised.Learning laws is essential.Good designing and applicating effective and efficient nursing documents are necessary.Reform of nursing process should help make practice safe.Training is a long and systematical task.A set of training programs should be provided and practiced.All of these should enhance nursing documents quality and protect clients and nurses.Good use of information of nursing documents should also promote nursing quality. Author's address Chaoyang Hospital,Beijing,100020 |
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| Keywords: | Nursing documents Standardized management Training and quality control |
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