护理文书书写质量检查分析与对策

[目的]进一步提高护理文书书写质量，防范医疗护理纠纷，加强护理文书书写环节质控。[方法]从2006年起不定期对我科现住病历进行随机抽查250份，并对检查结果进行分析。[结果]250份抽查护理文书中，护理记录单存在的缺陷较多。[结论]护理文书存在的问题主要是人为因素，加强护士在职教育、培养敬业精神、充分发挥护理管理人员的作用，可提高护理文书书写质量。

Checking and analysis of writing quality of nursing documents and its strategies

Objective： In order to enhance the writing quality of nursing documents and to prevent medical and nursing disputes, by organizing head nurses to check case histories randomly in every department, to verify patients, and to analyze causes of defects and then to put forward some corresponding strategies so as to strengthen the quality control of writing links of nursing documents, and to make sure the writing quality of nursing documents and nursing quality. Methods. A total of 250 case histories in hospital in our department were checked randomly and irregularly from 2006. And checking results have been analyzed. Results. There were more shortcomings in nursing recording lists among all 250 nursing documents. Conclusion： Problems existing in nursing documents are mainly anthropic factors. To strengthen professional education, to cultivate the spirit of revering occupation and to bring nursing administra- tors into fully play can enhance the writing quality of nursing documents.