摘要
降低精神科护理记录缺陷率,提高书写质量水平。对1243份出院的护理记录进行质量评价,其中496份护理记录存在缺陷分析其原因并实施相应对策,如学习《医疗事故处理条例》增强法律意识、加强护理记录书写的规范化培训、加大护理病历质量监控力度、加强素质教育及继续教育、保证护士工作时间及编制。
Objective： To reduce the defect rate of the psychiatric nursing recorders and improve the quality of their writing level. Methods： By means of evaluation on the nursing recorders of the psychotics discharged form Nov 2006 to Apr 2007, the reason of the defects was analysed and the stralegy relatively was carried out. To learned the （Rules of Dealing with the Medical Accidents）, to strengthen our nurse＇s law consciousness, to standardize the writing of nursing recorder, to traine and strengthene the supervisory control to the quality of nursing recoder and to suppont nursing staff were key points.
出处
《天津护理》
2008年第5期288-289,共2页
Tianjin Journal of Nursing
关键词
精神科
护理记录
缺陷
对策
Psychiatric
Nursing Recorder
Defect Strategy
