护理病历书写规范 课件.ppt

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,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,谢谢大家！,