目的总结电子护理记录的优越性。
Objective To summarize the superiority of electronic nursing records.
护理记录单；原因分析；防范对策。
目的完善急诊护理记录，避免医疗纠纷。
Objective Toimprove the emergency nursing records and to avoid medical disputes.
护理记录是医疗病历中的重要组成部分。
目的提高护理记录质量，保证其法律效用。
Objective To improve the quality of nursing records and ensure their effectiveness.
眼科；表格式护理记录单；临床应用；质量控制；
Ophthalmology Nursing record table format Clinical application Quality control;
笔者报道从法律角度分析护理记录中的缺陷及对策。
The authors report their analysis of nursing records at the angel of law and the countermeasures.
目的探讨护理记录中存在的缺陷并提出相对应的对策。
Objective To analyze the defects of nursing records and put forward corresponding countermeasures.
目的分析护理记录单纠纷隐患产生原因，并探讨相应防范对策。
Objective To analyze the reason of potential disputes in care records, and discuss the corresponding countermeasure.
前言：目的：分析护理记录单书写存在的问题，提高护理记录质量。
Objective: To analyze the questions of writing nursing records, for improving quality of nursing records.
护理记录作为病案的一部分，社会应用日益广泛，越来越被人们所重视。
As part of the medical record, the nursing record has got more and more attention and has been used widely.
结果在护理记录中加强书写和管理工作的规范，加强护理人员的责任意识。
The result strengthens to write in the nursing the record with management work of norm, strengthen the nursing personnel's responsibility consciousness.
方法用统一的质量标准检查380份护理记录单，对存在的缺陷分类列出。
Methods Inspected 380 nursing labels with the unification quality specification, listed the defect.
护理记录是病历的重要组成部分，也是病人诊断治疗过程中的重要法律依据。
Nursing records is an important part of medical records and is a important law grounds during diagnosis and treatment.
方法：从住院病历中随机抽取护理记录784份，由护理质控组进行质量评价。
Methods: 784 nursing records randomly selected from medical records were evaluated by nursing quality control group.
结论静脉输液管理的护理记录、敷料的护理、外周静脉通路的选择等方面需要改善。
Conclusion the nursing documentation of peripheral IV infusion management, IV dressing, and the selection of venous pathway of chemotherapy need to be improved during peripheral intravenous infusion.
目的：为保证手术护理记录单的完整性，提高手术护理记录单质量，降低缺陷发生率。
Objective to guarantee the integrity to enhance the quality to lower the incidence of defect of the operation nursing record.
方法对3000份手术护理记录进行检查，并将存在缺陷的记录进行分类总结、分析。
Methods 3000 surgical nursing recording sheet were checked, and defective recording sheet were classified, summarized and analyzed.
方法：回顾性分析我院近年来收治的50例骨折合并糖尿病患者的情况，并会查其护理记录。
Methods: a retrospective analysis in recent years admitted to our hospital, 50 cases of fracture in patients with diabetes, and will check their care records.
结论电子护理记录书写时间短，操作简单快捷，病历整洁，提高了工作效率及护理文书质量。
Conclusion Electronic nursing records, being simple to use and less time needed, neater and clearer, will improve...
方法用统一的质量标准检查952份护理记录单，对存在的缺陷用表格形式按百分比分类列出。
Methods Inspects 952 nursing labels with the unification quality specification, lacks to the existence hidden lists with the tabular form according to the percentage classification.
目的探讨呼吸科危重患者护理记录的质量建设，找出存在的问题，提出提高护理记录质量的措施。
Objective to discuss the changes of nursing records on the severe patients in respiration department so as to find out the existing problems and improve the quality of nursing records.
方法电子护理记录组50份，手写护理记录组50份，比较两组记录书写时间、书写质量及存在的问题。
Methods A total of 50 copies of electronic nursing records and 50 copies of hand-written nursing records were compared in terms of writing time, writing quality and shortcomings.
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。
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.
前言： 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。
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.
目的报道护理记录中存在客观、真实、准确、及时、完整等“五性”缺陷，分析原因，主动干预，回避医疗风险。
Objective To report 5-defections, in objectivity, reality, accuracy, punctuality and integrality, and to make cause analysis and active intervention, avoid medical risk.
为适应新的医疗法规条例的要求，通过分析护理记录中出现问题的原因，探讨记录的改进措施，以不断提高护理记录质量。
According to requirement of the medical rules, we analyzed the causes of the problems in nursing records and explored the measures to improve the quality of nursing records constantly.
为适应新的医疗法规条例的要求，通过分析护理记录中出现问题的原因，探讨记录的改进措施，以不断提高护理记录质量。
According to requirement of the medical rules, we analyzed the causes of the problems in nursing records and explored the measures to improve the quality of nursing records constantly.
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