摘要
目的:分析影响护理文件书写质量的相关因素,总结存在问题,制定护理文件书写改进措施。方法:采用回顾性调查方法,对我医院600份产科出院护理病历进行调查、统计和分析;采用问卷调查法及现场调查法,对各层次护理人员进行调查,分析护理病历书写质量问题及症结,制定科学对策。结果:600份护理病历书写普遍存在问题有:主观描述比较多、形式格式复杂、病人的动态变化不能完全体现等问题。这与人员结构层次、护理管理机制和法律意识等因素相关。结论:简化护理文件书写格式、加强质量监控管理、加强护理人员的法律意识、改革护理管理机制可以促进护理文件书写质量的提高。
Objective：To analyze of the quality of nursing writing that the relevant factors and summarize existing problems,to develop nursing documentation writing improvement.Methods：We reviewed and analyzed retrospectively 600 outpatient nursing documents from departments of maternity of our hospitals.Different levels of nursing staff were investigated by on-the-spot questionnaire.Results：Problems commonly existing in nursing document writing included too much subjective description,redundantstereotype and incomplete recording of patients’dynamic changes. These problems were related to such factors as the nursing management system,stratification of nursing staff and legal awareness.Conclusion：Streamline nursing documentation written format,to strengthen quality control management,strengthen the legal awareness of nursing staff,the reform of nursing care and management can improve the quality of the file written.
出处
《护理实践与研究》
2010年第24期97-99,共3页
Nursing Practice and Research
关键词
护理文件
书写质量
分析
产科
改进措施
Nursing documentation
Writing quality
Analysis
Maternity
Improvement measures
