护理文件书写的质量管理

护理文件书写的质量管理应为有组织的规范化管理。重在训练基本功,提高护理人员整体素质。在此项工作质量管理中实行护士、护士长、护理部质控人员三级管理,重要环节是病区护士长对护理文件记录的质量把关和环节、终末质量控制,严格执行各级检查及考评制度,上下配合,信息沟通。质控人员掌握全院护理文件书写的质量动态,并根据存在的各种问题及时给予纠正和指导。如此循环往复的质量控制,必将提高护理文件书写的整体水平。

Quality control of the writing of nursing documents

The quality control of the writing of nursing documents should be systematical and standard. The key points in the writing are the training of basic skills and the improvement of the overall quality of nurses. The head nurse in a ward is in charge of the writing quality of records and graphs in every link and end quality control. The administrator of the nursing department is to supervise the writing quality and examination of the nursing documents in the whole hospital and give instructions and corrections in time when problems appear. Thus the quality of the nursing documents can be improved.