哈尔滨医药2016，Vol.36Issue(5)：565-566,567,3.
成人首次护理记录单书写质量缺陷分析与管理对策
Analysis and Management Countermeasures of the Quality Defects of the First Nursing Records
廖华1
作者信息
- 1. 中山市博爱医院病案统计室，广东中山528403
- 折叠
摘要
Abstract
Objective To explore the method of improving the quality of the first nursing records of the patients admitted to the hospital for the first time in order to reduce the error of the first nursing record.Methods From June 2014 to 2015 January,ad-mission archived adult patients with the first nursing record single 3482 copies,the analysis found that which of the defects and summarized,explore solutions.Results In the examination of 3482 medical records in the presence of quality defects of 98 copies, accounting for 2.8%of the total,a total of 111 times the quality of defects.Only once quality defects have 88;Two quality defects 8;Appear three times or more than three times the quality defects of 2.Conclusion The first nursing record single exist more serious problems,the nursing staff should be enhanced their awareness of the law and strengthen between doctors and nurses,nursing com-munication between patient and strengthen the study of professional knowledge,strengthen consciousness of medical record writing standard,perfect quality control team,and in nursing,nursing between the patients and the legitimate rights and interests can be guaranteed.关键词
首次护理记录单/质量缺陷/管理对策Key words
First time nursing record sheet/Quality defect/Management分类
医药卫生引用本文复制引用
廖华..成人首次护理记录单书写质量缺陷分析与管理对策[J].哈尔滨医药,2016,36(5):565-566,567,3.
