[医药卫生]护理病历书写规范.ppt

Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo 护理记录: 应当根据医嘱、疾病护理常规和病情变化动态地进 行记录。对危重患者、手术患者、心电监护的患者应当根据病 情每班至少记录一次，有病情变化随时记录。 Company Logo Company Logo Company Logo Company Logo LOGO 湖北省护理文件书写规范 王哲敏 襄樊职业技术学院附属医院 Company Logo 护理病历: 是体现护理行为的法律依据，护理记录动态反映了护士的观察、护理措施、治疗效果等。也是护理专业价值的文字依据，所以必须 “做你所写、写你所做的”。 把时间还给护士， 把护士还给病人。 Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo 护理记录: 是护士对住院患者全过程进行客观、真实 准确、及时、完整的记录，它不仅反映临床 护理质量、护理水平，而且也反映出护士观察 问题、分析问题及解决护理问题的能力。 Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo Company Logo LOGO