护理文书内涵质量的分析与对策  

Analysis and Countermeasures on Influencing Factors of Nursing Records' Qualities

作　　者：韩慧娟[1] 韩晨光[1] 李玉明[1] 程晨[1] 邸红军[1] 姚利秀[1] 

机构地区：[1]武警医学院附属医院护理部,天津300162

出　　处：《解放军医院管理杂志》2006年第9期730-732,共3页Hospital Administration Journal of Chinese People's Liberation Army

基　　金：武警医学院科研基金项目(编号:WY2006-24)

摘　　要：影响护理文书内涵质量的因素主要包括护士自身素质及业务能力和科室管理水平两个方面,通过制定护理文书书写规范、建立健全护理文书三级质控、加强法律责任意识教育、严格落实护理规章制度、业务培训与质量讲评相结合、加强医护交流和护患沟通等举措,能够稳步提高护理文书的内涵质量。The main influencing factors of nursing records′s qualities included self-qualification,professional abili- ty and the level of department management.The paper proposed to set down writing criterions,establish and perfect the three-level quality control system for nursing records,enhance consciousness educations,carry out the rules and regulations strictly,link profession training and quality commenting,increase interchanging between doctors and nurses,and promote friendly relations between nurses and patients to improve the intrinsic quality of nursing records.

关 键 词：护理文书 内涵质量 自身素质 业务能力 科室管理 

分 类 号：R197.32[医药卫生—卫生事业管理]