摘要
在《北京朝阳医院护理文书书写标准》实施过程中 ,护理部分别对运行中护理病历和终末护理病案共 198份进行检查 ,对护理病历中出现的护理记录内容不具体、重点不突出、记录不及时准确、不客观等问题进行了分析 ,并认为提高护理人员对护理病历书写重要性的认识 ,是保证护理病历质量的前提 ;加强护理病历书写技能、护士观察能力和疾病症状学知识的培训 ,是提高护理病历质量的重要环节 ;而加大护理病历质量的监控力度 ,制作护理病历模板 ,实施弹性排班 ,是提高护理病历质量的手段。
Based on 'the Standards of Nursing Documents in Beijing Chaoyang Hospital', the Nursing Department examined the whole of 198 case documents uncompleted and completed. Some problems were analyzed, such as ambiguous content, unclear emphasis, delayed and incorrect record and subjective judgment etc. It implied that understanding the importance of writing nursing cases should be essential to the nursing document quality. And reinforcing the skill training in writing nursing cases and observation and semeiography should be a good approach. Therefore, it would be necessary to enhance quality supervision, develop the document model, and perform the flexible shift arrangement.
出处
《护理管理杂志》
2003年第6期19-21,共3页
Journal of Nursing Administration
关键词
护理病历
书写过程
问题
对策
nursing cases
writing process
problem
strategy
