摘要
目的 :探讨如何规范中医护理文书 ,以适应《医疗事故处理条例》的要求。方法 :采用护理部不定期抽查、护士长夜查及质控员交叉检查相结合的方法 ,对住院病历进行环节质控和终末质控。结果 :通过加强对中医护理文书的质控 ,找出存在的问题并提出相应对策 ,有效地提高了中医护理文书的书写质量。结论 :规范书写 ,规范记录 ,科学地记录诊治患者的每一个环节 ,确保病历中各项护理文书的质量 ,可发挥中医护理文书在“举证责任倒置”
Objective:To explore how to standarize traditional Chinese medical nursing document in accordance with the Regulation for Medical Malpractice Disposal.Method:To control the nursing record quality of inpatient's record book by the way of nursing department's non-regular inspection and head nurse's night check as well as quality controller's cross-inspect at mid-term and end-term.Result:The quality control of traditional Chinese medical nursing document,was enhanced the existing problems and solved them,were found out the record quality of traditional Chinese medicine document effectively can be improved.Conclusion:To standardize nursing document and record,to record inp^atient's diagnosis honestly by every step,and to ensure the nursing record quality of inpatient's record book,is important for the traditional Chinese medical nursing document to be used under the reversing burden of proof according to the Regulation for Medical Malpractice Disposal.
出处
《齐鲁护理杂志》
2004年第1期20-21,共2页
Journal of Qilu Nursing
关键词
中医
护理文书
护理记录
护理质量
护士
Medicine,Chinese traditional
Nursing record
Nursing quality check
