护理文书书写缺陷分析与对策

Strategy and analysis of nursing documents writing deficit

目的探讨提高护理文书书写质量的有效途径。方法按广东省卫生厅编制《临床护理文书规范》对我院2010年1月～2012年12月的出院病历进行终末质控。结果我院2010～2012年各月份出院病历护理文书书写缺陷率逐月下降。结论提高护士护理文书书写能力，增强护理人员的工作责任心，提高护理人员的业务素质，加强护理质量管理，有助于提高护理文书书写质量。

Objective To explore the effective way for improving the quality of nursing documents writing. Methods The discharge case file from January 2010 to December 2012 in our hospital,were conducted terminal medical quality control according to the clinical nursing documents standard written by Health Bureau of Guangdong Provincial. Results The nursing documents writing defect rate in our hospital was declined month by month from 2010 to 2012. Conclusion To improve nursing documents writing ability,work responsibility and nursing specialty quality of clinical nurses,and strengthen the management of nursing quality,which are helpful for improving nursing documents writing quality.