信息化管理下护理文件缺陷分析与管理对策  

Nursing document defect analysis and management strategy under informational management system

作　　者：辛燕飞[1] 

机构地区：[1]解放军第251医院儿科,河北省张家口市075000

出　　处：《中国护理管理》2009年第3期34-35,共2页Chinese Nursing Management

摘　　要：目的:通过对出院病历中护理文件的缺陷分析,找出管理中的原因,提出管理对策。方法:随机抽取归档护理文件250份进行分析。结果:检查发现信息化管理下护理文件存在的缺陷较原来减少,但护理文件的缺陷仍较多。结论:缺乏法律意识,责任心不强,业务知识缺乏,文字表达能力差,质控不力等是发生护理文件缺陷的原因。objective：To identify the management causes and coping strategy of nursing document defect after analyzing discharged medical chart. Method： Two hundred and fifty discharged medical charts were random selected and analyzed. Results： There were fewer defects in medical charts than before, but many defects did exist under informational management system. Conclusion： Many reasons, such as short of legal consciousness, lack of responsibility and professional knowledge, low written communication ability, and ineffective quality control could cause nursing document defects.

关 键 词：信息化 护理文件 护理工作 护理管理 

分 类 号：R47[医药卫生—护理学]