摘要
目的探讨、分析神经外科护理记录的主要问题及其发生原因及解决对策。方法收集、统计我院神经外科病历护理记录中出现的主要问题。结果 2012年191份护理记录存在问题,不规范率占到39%,2013年有128份,护理记录不规范率为13.1%。结论制定一套规范的书写标准,从而提高神经外科护理记录的书写质量。
Objective To investigate, analysis of the main problems of Department of Neurosurgery nursing records and its causes and countermeasures. Methods The main problem collection, statistics of nursing records records appeared in the Department of neurosurgery in our hospital. Results The existing problems in 2012 there were 191 nursing records, not standardized rate accounted for 39%, in 2013 there were 128, nursing records are not standardized rate was 13.1%. Conclusion To formulate a set of standardized writing standard, so as to improve the quality of Department of Neurosurgery nursing records.
出处
《中国继续医学教育》
2015年第8期163-164,共2页
China Continuing Medical Education
关键词
神经外科
护理记录
问题
原因
对策
Neurosurgery, Nursing record, Problem, The reason,Countermeasures
