【摘要】 目的:探讨规范危重病患者护理记录书写应遵循的原则和规范,提高护理病历质量。方法:对362份危重病患者护理记录单存在的缺陷进行统计分析。结果:确定了危重病患者护理记录单的缺陷原因,提出相应的干预措施,保证护理质量和病案的完整性。结论:要加强质量监督,确保护理文书的规范化,以防护理纠纷的发生,便于医院内病案实行统一规范化。更多还原

【Abstract】 Objective: To explore the standard of nursing records of critical patients. Methods: 362 nursing records of critical patients have been investigated. Results: the reasons for deficiencies have been found and countermeasures have been proposed. Conclusion: The quality control of nursing records of critical patients should be strengthen in order to standardize nursing record and prevent nursing dispute.更多还原