| 护理文书书写中的细节管理 |
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| 引用本文： | 邓小球. 护理文书书写中的细节管理[J]. 中华医护杂志, 2005, 2(5): 462-463 |
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| 作者姓名： | 邓小球 |
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| 作者单位： | 湖南省安化县中医医院护理部,湖南安化413500 |
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| 摘 要： | 目的提高护理病历书写质量，为医疗举证提供客观、真实的病历资料。方法应用细节管理知识结合病历书写质量管理对护理人员常存在的问题进行干预。结果实施细则管理后有效地减少了护理记录中存在的问题，提高了护理病历质量，前后两年比较具有高度显著性差异p〈0．01。结论好的护理记录可以印证医生病历内容，弥补医院病历的不足，成为护理人员保护自身合法权益的重要证据。
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| 关 键 词： | 医疗机构 护理记录 病历管理 |
| 文章编号： | 1812-7851（2005）05-0462-02 |
| 收稿时间： | 2005-09-15 |
Detailed Management in Nursing Document Writings |
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| Deng Xiaoqiu. Detailed Management in Nursing Document Writings[J]. Chinese Journal of Medicine and Nursing, 2005, 2(5): 462-463 |
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| Authors: | Deng Xiaoqiu |
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| Abstract: | Objective To increase writing quality of nursing case history and provide medical testification with objective and substantial data of case history. Methods The problems existed frequently in nursing staff were interfered in by using detailed management knowledge combined with quality management of case history writing. Results Problems existed in nursing record were reduced and quality of nursing case history was elevated Conclusion Favourable nursing record can test contents of case history described by physicians and make up for inadequacy of hospital, which has been major evidence of safeguarding legitimate rights and interests for nursing staff themselves. |
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| Keywords: | Medical institution Nursing record Management of case history |
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