摘要
通过随机抽查2013年实时病历、出院病历护理文件书写质量。结果发现,护理文件书写存在很多方面的缺陷。通过分析原因,提出整改措施,加强护理人员理论、专业技术培训,加强护理文件书写环节质控和终末质控,提高护理文件书写质量。
Objective:The writing quality of nursing documents in real time medical records and dischargged medical records were randomly checked in 2013.We found that there were many defects in many aspects in nursing document writing.Through analyzing the causes,some rectification measures were put forward.We should strengthen the nursing theory and professional and technical training,strengthen nursing documents writing process quality control and final quality control,and improve the quality of nursing documents writing.
