摘要
目的:分析基层医院护理记录存在缺陷,制定出相应干预措施。方法:对240份护理记录进行质量抽查。结果:240份护理记录存在缺陷118份,共有153处。结论:必须加强基层护理记录的检查与管理力度,重视护理人员的法律知识、文化素质及护理文书书写要求的培训,以规范护理记录的书写。
Objective To analyze the errors in the nursing records of primary hospitals and work out the intervention measures. Methods To evaluate the 240 pieces of nursing records. Results There were 153 mistakes in the 118 pieces of the total 240 nursing records. Conclusion In order to standardize the nursing records, it is necessary to stress the examination and the administration of the primary nursing records, and attach importance to the training of nurses＂ knowledge about law, culture and how to write a nursing record exactly.
出处
《安徽卫生职业技术学院学报》
2006年第5期8-9,共2页
Journal of Anhui Health Vocational & Technical College
关键词
基层医院
护理记录
缺陷
措施
primary hospitals
nursing record
error
measure
