强化护理病历书写提高护理记录质量

The strengthened nursing medical record writing, enhancement nurses the record quality

目的：探讨书写病历质量控制，进一步提高对护理记录质量及书写质量。方法：将我院住院300份护理病历质控后进行统计分析。结果：护理记录的完整性、真实性、客观性、准确性，护理病历达标率由质控前的81．55％升至质控后的98．85％，差异有统计学意义（P〈0．001）。结论：护理记录质量控制措施的实施，能够有效的提高护理记录质量和书写质量避免因护理记录书写引起的法律纠纷。

Objective：Discusses the written medical record quality control, further enhances to nurses the record quality and the written quality. Methods：After is hospitalized my courtyard 300 nursing medical record nature controls, carries on the statistical analysis. Results： Nurses the record the integrity, the authenticity, the objectivity, the accuracy, the nursing medical record success rate controls after the nature 81.55% to climb to the nature to control 98.85%, the difference has statistics significance （P〈0. 001）. Conclusion：Nurses the record quality control measure the implementation, because can the effective enhancement nurse the record quality and the written quality avoids nursing the legal dispute which record writing causes.