護理病歷書寫規(guī)范 課件

湖北省護理文件書寫規(guī)范王哲敏襄樊職業(yè)技術學院附屬醫(yī)院

湖北省護理文件書寫規(guī)范CompanyLogo護理病歷:是體現(xiàn)護理行為的法律依據(jù)，護理記錄動態(tài)反映了護士的觀察、護理措施、治療效果等。也是護理專業(yè)價值的文字依據(jù)，所以必須

“做你所寫、寫你所做的”。

把時間還給護士，把護士還給病人。CompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogo護理記錄:是護士對住院患者全過程進行客觀、真實準確、及時、完整的記錄，它不僅反映臨床護理質量、護理水平，而且也反映出護士觀察問題、分析問題及解決護理問題的能力。CompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogo

護理記錄:應當根據(jù)醫(yī)囑、疾病護理常規(guī)和病情變化動態(tài)地進行記錄。對危重患者、手術患者、心電監(jiān)護的患者應當根據(jù)病情每班至少記錄一次，有病情變化隨時記錄。

CompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLo謝謝大家！謝謝大家！湖北省護理文件書寫規(guī)范王哲敏襄樊職業(yè)技術學院附屬醫(yī)院

湖北省護理文件書寫規(guī)范CompanyLogo護理病歷:是體現(xiàn)護理行為的法律依據(jù)，護理記錄動態(tài)反映了護士的觀察、護理措施、治療效果等。也是護理專業(yè)價值的文字依據(jù)，所以必須

“做你所寫、寫你所做的”。

把時間還給護士，把護士還給病人。CompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogo護理記錄:是護士對住院患者全過程進行客觀、真實準確、及時、完整的記錄，它不僅反映臨床護理質量、護理水平，而且也反映出護士觀察問題、分析問題及解決護理問題的能力。CompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogoCompanyLoCompanyLogo

護理記錄:應當根據(jù)醫(yī)囑、疾病護理常規(guī)和病情變化動態(tài)地進行記錄。對危重患者、手術患者