摘要
目的分析骨科护理记录存在的问题,进一步完善和规范护理记录书写内容。方法回顾分析书写护理记录以来存在的问题,制订符合骨科疾病护理特点的护理记录模板。结果现行的护理记录模板内容详细,具有专科特点,能反映病人在住院过程中的动态变化及治疗护理的全过程。结论护士根据护理记录模板书写护理记录,对护理记录的书写质量有积极的促进作用。
Objective To analyze the problems in nursing records in orthopaedic department,and to improve and standardize the contents of nursing records. Method Retrospective analysis was conducted on the problems in nursing records. Then,a nursing records model was designed and applied according to the characteristics of orthopaedic department. Result The nursing records model has detailed contents and its own special features,which can refleet patients＇ dynamic changes and the whole course of nursing and treatment during hospitalization. Conclusion It is beneficial to write nursing records according to the nursing records model to improve the quality of nursing records.
出处
《护理管理杂志》
2006年第6期50-50,56,共2页
Journal of Nursing Administration
关键词
护理记录
模板
制订
书写
nursing records
model
establishment
writing
