护理文件书写
护理文件书写-
护理文件书写质量现状分析及品质改进
Quality of Nursing Documentation : Current Status and Methods of Improvement
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新时期对护理文件书写的重新认识
Re-recognition on Nursing Documents Writing in the New Era
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护理文件书写中常见问题原因分析与对策
Analysis on the reasons and countermeasures of the common problems in nursing documentation
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护理文件书写的质量管理应为有组织的规范化管理。
The quality control of the writing of nursing documents should be systematical and standard .
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目的调查和分析影响护理文件书写质量的相关因素，探讨护理文件书写品质改进策略。
Objective To investigate and analyze related factors affecting the quality of nursing documentation , and discuss improvement methods .
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结果规范管理后护理文件书写质量明显提高（P<0.01），前后比较差异有显著性。
Results The quality of nursing document writing improved obviously ( P < 0.01 ) after standardized management . Difference is remarkable to make a cross-reference .
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目的针对护理文件书写存在的缺陷，进行规范管理，从而提高护理文件书写质量。
Objective According to the standardized management in allusion to the existent defect in the nursing document , thus to improve the nursing document writing quality .
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质控人员掌握全院护理文件书写的质量动态，并根据存在的各种问题及时给予纠正和指导。
The administrator of the nursing department is to supervise the writing quality and examination of the nursing documents in the whole hospital and give instructions and corrections in time when problems appear .
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护理医疗文件书写中存在的问题是造成近年来医疗护理纠纷处理难，使护理工作陷于被动状态的原因之一。
Recently , the problem in writing nursing medical documents is one of the causes for medical and nursing disputes to be settled with difficulty and for nursing work to be in a passive state .
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结果护理技术操作合格率、基础护理合格率、护理文件书写合格率均在96%以上；
Results The eligible rate of nursing manipulation , basic nursing and nursing writing were all over 96 % .
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因此，为了提高危重病人护理记录质量，针对不同护士进行有针对性的护理文件书写培训十分必要，同时制定全国统一的护理记录标准是目前提高护理医疗文件质量的当务之急。
It is necessary to provide training for the nurses in writing the nursing documents and establish national standard in nursing records , so as to improve the quality of critical patients ' nursing records .
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结论护理电子病历使护士书写方便、快捷和规范，提高了工作效率和质量，实现了护理文件书写信息化管理。
Conclusion The nursing electronic clinical record is convenient , rapid and standardized . It can improve work quality and efficiency . It also achieves information management of nursing files .
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结论社区护理工作的规范化管理可提高护理服务质量，此次制定的各项制度、职责和护理文件种类及书写规范尚待在实践中进一步完善。
Conclusion The standardized management of community nursing care can improve the quality of the nursing service . The drawn systems , responsibilities and nursing files await further improvement in the future .