摘要
目的探讨整体护理病历中存在的问题并分析其原因。方法随机抽样整体护理病历60份，分为A组（工作5年以上护士书写）和B组（工作5年以下护士书写），每组病历30份，进行统计分析。结果从护理资料收集、护理诊断及护理计划等方面，B组发生错误的百分率均高于A组，并以护理诊断最为明显。结论加强护理诊断训练及年轻护士的培养和指导是提高整体护理病历质量的关键。
Objective To investigate problems in holistic nursing care case recording and analyze the causes for these problems. Methods 60 random samples of holistic nursing care cases recording were classified into two groups:Group A,written by nurses with more than 5 years of employment,and Group B,written by nurses with less than 5 years of employment,and analyzed statistically. Results Group B had higher percentage of error making in nursing data collection,nursing diagnosis and nursing planning than Group A. Conclusion Strengthening training in nursing diagnosis and intensify the training and supervision of young nurses are essential for raising the quality of holistic nursing care case recording
出处
《解放军护理杂志》
2000年第3期12-13,共2页
Nursing Journal of Chinese People's Liberation Army
