规范护理文件资料管理 提升优质护理内涵建设

Standardized Management of the Nursing Documentation, Enhancing Connotation Construction of High Quality Nursing Care

目的通过规范护理文件资料管理,提高护士工作质量和效率,提升优质护理服务及管理水平。方法结合ISO9001质量管理体系认证标准,建立文件资料管理框架,按行政管理、业务管理、护理安全管理、服务对象评议、护理科研和教学、护理文化信息与活动六大类文件资料,分别建立目录、进行编号、归档保存。结果文件资料控制程序和方法的建立应用,方便护理人员对文件资料的使用、查询、追溯和保管。结论科学化、规范化的管理,使护理文件资料归档管理井然有序,保障了护理管理的连续性、有效性及可追溯,对减少护患纠纷隐患,增强护患关系和谐起到积极作用。

Objective To standardize nursing documentation management, enhance the level of care management. Methods Combined with ISO 9001 quality management system certification standards, after finishing classification of nursing documentation, creating a directory and archiving, establish and maintain standardized documentation controlling procedures. Results Nursing documentation can be divided into six categories as administration, business management, nursing security management, service objects council, nursing research and teaching, nursing cultural information and activities, pursuant to which we can establish a standardized, scientific documentation management framework and conduct a standardized management. Conclusion The standardized management makes the nursing documents archiving orderly, which ensures scientific and continuity of care management. To reduce nurse- patient disputes dangers, enhazlce nurse-patient relationship plays a positive role.