落实国家卫生部2010《病历书写基本规范》的思考

The thinking of implementing 《The Basic Criteria for medical records documents 》 issued by Ministry of Health of PRC in 2010

目的 贯彻落实国家卫生部2010年印发的〈病历书写基本规范〉的思考.方法 对照新规与旧规,找出异同,对与手术相关（直接或间接）的改进部分深入分析思考.结果 按照新规,手术室重新修订清点记录单,制订落实方案.结论 新年伊始印发新的〈病历书写基本规范〉是加强护理工作的重要举措.新的规定更符合手术室工作性质,更有利于护理人员集中精力满足手术所需,对医疗护理行为有很强的导向作用.

Objective To implement 〈The Basic Criteria for medical records documents 〉 issued by Ministry of Health of PRC in.2010. Methods To compare new criteria and old one, find the similarities and differences, deeply consider and analyze the improvement related to operation both directly and indirectly.Results The record table of amount checking was revised according to new criteria and a plan was made to implement it. Conclusions At the beginning of the year, the publishing of this new regulation is an important measure for improving the nursing quality. The new criteria are in accord with the work in operation room, it can promote nurses＇ attention and direct medicine and nurse activities effectively.