摘要
目的:找出儿科归档病历中护理记录存在主要共同问题,针对问题提出应对方法,进一步提高护理质量。方法:随机抽取儿科归档护理记录200份,将所存在问题合并归类,然后就问题共性进行分析。结果:在200份护理记录中发现问题316处,占抽查病历的93%。结论:严格护理记录书写规范是保证护理记录真实有效的必要手段。
Objective:To find out the main defects and introduce corresponding solutions in nursing records of filed medical history in department of pediatrics so as to improve the quality of nursing.Methods:200 nursing records of filed medical history in department of pediatrics were examined.The common problems existed in these records were classified and analysed.Results:Altogether 316 defects were found out,which accounted for 93% in the 200 nursing records examined.Conclusion:It is necessary for strict handwritin...
出处
《华西医学》
CAS
2007年第4期896-897,共2页
West China Medical Journal
关键词
儿科
护理
Pediatrics
Nursing
