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整体护理病历的书写(The writing of holistic nursing records)
整体护理病历的书写(The writing of holistic nursing records)
Since the implementation of holistic nursing care, people began to explore the experience of holistic nursing record writing, but still does not have a unified mode and standard, the writing level is not high; the analysis mainly has the following several factors:
1, as a new type of nursing work, holistic nursing is not fully aware of it and can not understand its essence.
2, nursing staff have insufficient understanding of the significance of writing holistic nursing records.
3, there is no unified model and writing standard.
4, nurses badly missing.
5, the professional quality of nursing staff needs further improvement.
Due to the influence of these factors, the writing level of the holistic nursing record is not high.
Our hospital has 97 years to carry out holistic nursing, repeated exploration and Research on nursing record writing, and gradually formed a writing mode of holistic nursing care records for our hospital, now introduce to you for reference and exchange passage nursing. In the process of writing nursing records, we realize that only by fully understanding the meaning of the writing of holistic nursing care records, clear the contents of holistic nursing care records, medical records of the whole number of written specification requirements, in order to improve the level of comprehensive nursing records.
1, the significance of writing holistic nursing records
There are medical and nursing data for the current inpatient medical record analysis, but the so-called nursing information is only the temperature list and the orders of doctors orders. Can these two records reflect the contents of the nursing work? Obviously, no hospital patient should have two medical records, that is, medical records and nursing records, to reflect all the medical care of the patient during the hospital. But it has long been influenced by biomedical models and functional care. The nursing records of nursing work, resulting i
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