【摘要】 目的不断强化护理记录的客观性、真实性、准确性及完整性,持续提高护理记录质量。方法护士长对护理记录质量控制把握3个环节及10大要点。结果护理记录合格率从91.2%提高到95.8%,护理人员的书写能力及专科知识水平均得到提高。结论护士长采用严格、规范的护理记录质量控制方法,可有效提高护理人员书写护理记录的能力和专科知识水平及护理记录质量。更多还原

【Abstract】 Objective To enforce the objectivity,authenticity,accuracy and integrality of nursing records and to improve the quality of nursing records constantly.Method The head nurses emphasized on the three links and 10 essentials in the quality control of nursing records.Results As a result,the qualified rate of nursing records increased from 91.2% to 95.8%,and the nurses’ ability of writing and specialty knowledge had been improved obviously.Conclusion The head nurses taking strict and standardized means of quality control of nursing records could effectively improve the nurses’ ability of writing nursing records and their specialty nursing knowledge and promote the quality of nursing records.更多还原