关于护理病案书写质量的讨论  

A Discussion on the Quality of the Documentation of the Filed Nursing Medical Records

作　　者：章一华[1] 王丽霞[1] 

机构地区：[1]江西省赣州市人民医院质控科

出　　处：《中国病案》2007年第6期15-16,共2页Chinese Medical Record

摘　　要：目的探讨提高护理归档病案书写质量的对策，进一步提高护理质量。方法参照江西省《病历书写基本规范（试行）》实施细则及医院管理年活动中“护理文书书写质量评价标准”，就我院2006年1月-12月的13，396份护理归档病案终末质量进行持续监控。结果护理人员自觉参与质控意识增强，护理文书书写质量明显提高。Objective To investigate and discuss the improvement of the quality of the documentation of the filed nursing medical records. Method Consulting Detailed Implementing Regulations of the Basic Criterion of the Documentation of the Medical Record （Trying out） of Jiangxi Province, and Evaluation of the Quality of the Documentation of Nursing, we inspired the 133396 filed nursing medical records the hospital from Jan. to Dec. 2006. Result The nurses participated the program and their sense of quality has improved, and the quality of nursing documentation has been remarkably improved.

关 键 词：护理病案 病案质量 

分 类 号：R47[医药卫生—护理学]