| 儿科运行电子护理文书缺陷分析及对策 |
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| 引用本文： | 杨秀玲.儿科运行电子护理文书缺陷分析及对策[J].中国当代医药,2014,21(9):154-156. |
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| 作者姓名： | 杨秀玲 |
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| 作者单位： | 杨秀玲(江西省九江市儿童医院儿内科,江西九江,332000)； |
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| 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。
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| 关 键 词： | 电子护理文书 三级质控 缺陷 对策 |
Analysis of the pediatric operation of electronic nursing records defects and countermeasures |
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| Authors: | YANG Xiu-ling |
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| Institution: | YANG Xiu-ling;Department of Internal Medicine,Children′s Hospital of Jiujiang City in Jiangxi Province; |
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| 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 elec- tronic nursing records. |
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| Keywords: | Electronic nursing records Three-level quality control Defect Countermeasure |
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