护理文书的规范及管理分析

目的 提高护士针对护理对象在医疗护理活动过程中逐字、逐时、逐日连续和及时分别记录的既统一又绝对一致的病人疾病发生、发展、诊疗、护理、转归、客观和系统地记录的真实反映，提高医疗安全意识，规范医疗护理行为，规范医疗护理文书记录。方法参照广东省《病历书写规范》实施细则及医院管理年活动中”护理文书书写质量标准”，对临床运行及终末护理文书就其病案管理质量和病案内涵质量进行抽查综合分析、持续监控，提出合理化建议和管理措施。结果护理记录存在问题的及时反馈，更加客观、真实、准确、及时、完整地记录病人基本情况及护理措施，规范护理文书书写。结论加强法律知识培训，提高执业风险意识、”写我所做”、”做我所写”。实现自我保护，规范护理文书，提高医院医疗护理文书书写质量。

Analysis in standardized management of nursing documentation records

Objective To improve the true reflection of nurses＂ objective and systematical records of the disease occurrence, development, diagnosis and treatment, nursing, and outcome word by word, hourly, daily, continuously and in time respectively in the unified and unanimous way during the medical care, to enrich the medical safety knowledge, standardized medical care and health care documentation records. Methods Referring to ＂ Writing Norses of Case History＂ in Guangdong province and ＂ Quality Standard of Care Writ＂ in hospital management activities, make selective examination and comprehensive analysis of the cases management and connotation quality of the clinical operation and terminal care writs, continuously monitor, and put forward reasonable sugges- tions and management measures. Results The timely feedbacks of the problems in nursing records make more objective, true, accurate, timely and complete records of patients＇conditions and nursing measures, standardized nursing handwriting. Conclusion Strengthen the legal knowledge training, improve the awareness of risks, ＂write what I do＂ and ＂do what I write. ＂ achieve self-protection, standardize care handwriting, and improve quality of hospital nursing handwriting.