护理文书的质量控制与缺陷管理

Care Instruments Quality Control and Defects Management

护理记录是护理人员对患者病情变化和实施护理措施的客观记录,护理文书的书写是临床护理工作中很重要的一个环节,无论在临床治疗、护理水平研究、法律上、教学管理上均有不可估量的价值。本文针对护理文书存在的记录不真实和不全面;记录不及时和不连续、漏开医嘱、乱改记录以及护理人员缺乏法律观念等缺陷,提出加强护理文书监管体制的建立、加强文书书写培训、加强医护及护患之间的沟通、规范补充和修改护理记录环节、增强护士的法律意识,以全面综合提高护理文书的质量。

Nursing care records are implemented on the patient＇s condition changes and the objective record of care measures, Writing instruments, is a very important aspect about clinical nursing care.In terms of clinical treatment, the level of care, law, teaching management are invaluable. This paper documents the existence of this instrument for nursing records untrue, incomplete; Records are not timely, not continuous; open drain doctor; chaotic change records; And the nurses lack of legal concepts and other defects, proposed to strengthen the regulatory regime of the establishment of nursing documents ; Strengthen the training of writing instruments ; and strengthen health care and communication between nurses and patients; Specification to add, modify aspects of nursing records, and enhance the legal awareness of nurses to improve the comprehensive quality of care instruments.