| 护理文件书写中存在的问题及缺陷因素分析 |
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| 引用本文： | 邢彩霞.护理文件书写中存在的问题及缺陷因素分析[J].内蒙古医学杂志,2007,39(8):1011-1013. |
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| 作者姓名： | 邢彩霞 |
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| 作者单位： | 内蒙古自治区医院护理部,内蒙古,呼和浩特,010017 |
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| 摘 要： | 目的:分析护理记录单书写存在的问题,提高护理记录质量。方法:从住院病历中随机抽取护理记录784份,由护理质控组进行质量评价。结果:护理记录单书写中存在的缺陷依次为内容缺乏连续性、记录治疗内容多护理内容少、缺乏个性化、语言表达不准确、记录不及时、不全面、使用医学术语不恰当。结论:加大护理记录单的检查与管理力度,重视护理人员的法律知识、病历书写知识、专业知识、质量监控知识和文化素质的培训,以规范护理记录的书写。
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| 关 键 词： | 护理记录 缺陷 分析 |
| 文章编号： | 1004-0951（2007）08-1011-03 |
| 修稿时间： | 2006-03-15 |
Analysis in Questions and Deficient During Writing in Nursing Document |
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| XING Cai-xia.Analysis in Questions and Deficient During Writing in Nursing Document[J].Inner Mongolia Medical Journal,2007,39(8):1011-1013. |
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| Authors: | XING Cai-xia |
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| Institution: | Nursing Department,Inner Mongolia Hospital,Huhhot 010017 China |
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| Abstract: | Objective:To analyze the questions of writing nursing records,for improving quality of nursing records.Methods: 784 nursing records randomly selected from medical records were evaluated by nursing quality control group.Results: The questions in nursing records included discontinuous content,lack of nursing content,less individuation,inaccurate express,overdue and uncomplete records and inaccurate medical terms.Conclusion: The examination and monitor in nursing records,training in law knowledges,writing technique in medical records,specialized knowledge,informations about quality control and culture ability should be emphasized. |
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| Keywords: | Nursing record Defect Analysis |
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