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Application of writing long-term testament implementation paper and nursing record together
Author(s): 
Pages: 633-634
Year: Issue:  7
Journal: CHINESE JOURNAL OF NURSING

Keyword:  长期医嘱单护理记录;
Abstract: 目的设计新型的护理记录单,改变目前护理文件书写分散的现状.方法通过电脑管理医嘱,将长期医嘱执行单与护理记录同时书写,替代传统的长期医嘱执行单、一般患者护理记录、危重患者护理记录、输液巡视记录卡及用氧登记巡视卡等.结果简化工作流程,减少书写内容,利于操作,便于质量控制.结论新型的护理记录单符合《病历书写规范》要求,能真实、客观、准确地反映患者在医院接受治疗护理过程的全貌.
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