589份归档护理文书书写缺陷调查分析

Analysis on writing quality of 589 nursing filed documents

目的:为了解护士在执行安徽省新版的《病历书写规范》的情况,进一步提高护理文书书写质量。方法:某院对589份归档病历中的护理文书进行质量评价,评价依据为安徽省《病历书写规范(修订版)》的《护理文书质量评定标准》及《护理文书质量评分表》。结果:589份按护理文书质量评定标准达到合格。结论:列出589份护理文书书写缺陷,分析产生原因,提出解决对策。

Objective To evaluate the nurses＇ understandings of The Writing Specifications of Medical Doc uments, and to improve the writing quality of nursing documents in our hospital. Methods： According to The Quality Standard of Nursing Documents Assessment and The Score List of Nursing Documents Quality of The Writing Specifications of Medical Documents （Revised edition） of Anhui Province, we evaluated the quality of the nursing documents of 589 filed medical records. Results All the records investigated were qualified . Conclusion The defects of the investigated nursing documents are listed to analyze the reasons, and then work out the countermeasures.