严格把好四关 提高护理文书质量

Strictly guarding four strategic points for improving the quality of nursing documents

护理文书和医疗文书一样,是客观反映患者病情变化及其治疗过程的档案。护理文书质量是医院护理质量管理中的重点和难点之一,其质量的好坏,将直接影响医院整体护理质量。本文介绍了严格把好四关(即人员素质关、文书处理关、环节终末控制关、反馈奖惩关),是提高护理文书质量的重大举措,使护理文书质量得到稳步提高。

Nursing documents, same as medical documents , are the records objectively reflecting the states of patient's conditions as well as the courses of their treatments. The quality of nursing documents is one of the focal points and difficult points in the administration of hospital nursing care. It may directly influence the whole situation of the hospital nursing work. This paper presents that rigorously guarding the 4 strategic points: the personal quality, the document processing, the control of every link and terminal end, and the feedback awards and penalties, is an important means to improve the quality of nursing documents, and lets it to be going up steadily.