护理文件书写质量考核标准

护理文件书写质量考核标准,,,

序号,"检查

内容",存在问题,分值

1,"三测本

1.0",1.1有刮、粘、涂等现象，未签字盖章,0.05

,,1.2眉栏填写不全,0.05

,,1.3时间栏未填,0.05

,,1.4每日测量后护士未签字或（和）盖章、印章不清晰,0.05

,,1.5体温、脉搏、与交班不符,0.05

,,1.6提前测温,0.05

,,1.7延后测温,0.05

,,1.8新入患者无记录,0.05

,,1.9转科、转床、出院、手术患者标注不清或未标记,0.05

,,1.10记录窜行、错误,0.05

,,1.11体温、脉搏未记录或记录不全,0.05

,,1.12涂改方式不正确,0.05

,,1.13与体温单不符,0.05

,,1.14四次温未测全,0.05

,,1.15发热、新入、手术患者未连接测温,0.05

,,1.16未记录大、小便次数,0.05

,,1.17患者实际排便次数与记录、医嘱不符,0.04

,,1.18周二未测体重,0.04

,,1.19科室原有记录未保留三个月,0.04

,,1.20字迹潦草、不能辨识,0.04

,,1.21书写颜色杂乱，不统一,0.04

2,"交班本

1.0",2.1书写格式错误,0.1

,,2.2未签字、未盖章,0.1

,,2.3体温单录入与三测本记录不符,0.05

,,2.4未记录血压（新入患者、手术患者等）,0.05

,,2.5眉栏填写不全、错误,0.05

,,2.6转入患者无病情相关说明,0.05

,,2.7姓名与诊断分布，不在一页,0.05

,,2.8有刮、粘、涂等现象，未盖章,0.05

,,2.9未写入院诊断,0.05

,,2.10单位书写不规范,0.05

,,2.11姓名诊断未对齐,0.05

,,2.12体温前后空两格，空格太大,0.05

,,2.13交班顺序不对,0.05

,,2.14交班本内容为空,0.05

,,2.15危重患者*书写不正确（位置、颜色）,0.05

,,2.16书写内容不全面,0.05

,,2.17新入院患者书写不正确（位置、颜色）,0.05

,,2.18护士长检查未盖章,0.05

序号,"检查

内容",存在问题,分值

3,"专项

护理

记录单

1.0",3.1实际输血时间与专项护理记录单不符,0.1

,,3.2未记录输血开始时间,0.1

,,3.3未签字或（和）盖章,0.1

,,3.4输血记录未记单位、量,0.1

,,3.5输血记录未记血型,0.1

,,3.6未记录输血结束时间,0.1

,,3.7记录与医嘱不符,0.1

,,3.8记录与实际病情不符,0.1

,,3.9未根据病情与医嘱记录,0.1

,,3.10有刮、粘、涂等现象，未签字盖章,0.1

4,"对接单

1.0",4.1术后返回病人未填写对接单,0.2

,,4.2提前书写,0.2

,,4.3眉栏填写不全、错误,0.2

,,4.4内容填写不全、错误,0.2

,,4.5未签字或（和）盖章,0.2

5,"输液巡视卡

1.0",5.1签字模糊字迹潦草，无法确认,0.1

,,5.2无输液巡视卡,0.1

,,5.3无患者家属签字,0.1

,,5.4护士未签滴速,0.1

,,5.5护士未签时间,0.1

,,5.6护士未签姓名,0.1

,,5.7提前写滴速,0.1

,,5.8提前收回,0.1

,,5.9未及时收回,0.1

,,5.10滴速填写与实际不符合,0.1

6,"重症护

记录

单

1.5",6.1无日间小结,0.1

,,6.2总结无文字描述,0.1

,,6.3总结格式不对,0.1

,,6.4护士印章不清楚,0.1

,,6.5签字模糊、字迹潦草，无法确认,0.1

,,6.6未签字或（和)盖章,0.1

,,6.7记录与实际病情不符,0.15

,,6.8液体出入量总结不及时,0.15

,,6.9页码不连续、未填,0.15

,,6.10眉栏填写不全,0.15

,,6.11频次未按每半小时（白班）、每小时（夜班）记录,0.1

序号,"检查

内容",存在问题,分值

7,"体温单

1.0",,

,,6.12病情变化未及时记录,0.1

,,6.13提前书写，造假,0.1

,,7.1无体重,0.05

,,7.2无脉搏,0.05

,,7.3无体温,0.05

,,7.4入院当天无血压记录,0.05

,,7.5入院当日无身高、体重（卧床除外）周二未测体重,0.05

,,7.6灌汤医嘱在体温单未体现,0.05

,,7.7大小便漏记,0.05

,,7.8未签字或（和）盖章,0.05

,,7.9与三测本不符,0.05

,,7.10引流记录位置不对、漏记,0.05

,,7.11体重输入时间错误,0.05

,,7.12新入院患者第一天有大、小便记录,0.05

,,7.13未彩色打印,0.05

,,7.14眉栏填写不全,0.05

,,7.15未使用电子体温单,0.05

,,7.16电子、手写混记,0.05

,,7.17出入量漏记,0.04

,,7.18新入、转入、手术、发热患者未测四次温,0.04

,,7.19底栏项目名称无单位,0.04

,,7.20手术、转入、死亡患者未录入名称,0.04

,,7.21手术患者晨未记录血压,0.04

8,"医嘱单

1.0",8.1未签字或（和）盖章,0.25

,,8.2打印后质控护士未盖章,0.25

,,8.3电子、手写混记,0.25

,,8.4有未执行医嘱,0.25

9,"病例

首页0.5",9.1未签字或(和）盖章,0.5

10,"护理等

级评级

表0.5",10.1护士未评,0.1

,,10.2未签字或（和）盖章,0.1

,,10.3提前书写,0.1

,,10.4医生未评,0.1

,,10.5评定次数不够,0.05

,,10.6无护理等级评定量表,0.05

11,"住院病人

首次评估单0.25",11.1疼痛患者入院8小时内未评估,0.15

,,11.2疼痛评