加强护理记录书写提高护理质量  

Strengthening the Documentation of the Nursing Record to Improve the Quality of Nursing

作　　者：吴颖娜[1] 范晓玲[1] 

机构地区：[1]天津市天津医院

出　　处：《中国病案》2006年第7期24-24,共1页Chinese Medical Record

摘　　要：《医疗事故处理条例》及最高人民法院《关于民事诉讼证据的若干规定》,对医疗市场提出了更高的要求。强化护士法制观念,提高护士整体素质,是保证护理记录质量的关键。护理人员应加强专业学习,树立法制观念;规范护理行为,严格执行护理记录原则。本文就在临床护理工作中如何提高护理记录内涵这一问题进行简述。Further requirements are shown for medical market in The Statutes of Dealing with Medical Accidents and The Regulations on Civil Litigation Evidence from the Highest-class People＇s Court. Strengthening nurses＇ legal consciousness and raising all nurses＇ quality is the key to insure the quality of nursing records. This paper primarily discusses how to improve the intension of nursing records in nursing practice with suggestions followed： strengthening theoretic study and legal consciousness; regulating nursing actions, carrying out the principles of the nursing record strictly.

关 键 词：护理质量 护理记录内涵 医嘱 护理行为 护理记录原则 

分 类 号：R47[医药卫生—护理学]