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临床护理文书书写规范【附PPT版】

  • 2026-11-07 18:25:49
临床护理文书书写规范【附PPT版】

1

护理文书书写规范

护理记录的意义和重要性

护理记录在医疗纠纷中是法庭接受的法律证据。在保险理赔中，它可以是判断依据。在医疗质量评价中，它能反映护理水平。

护理记录上每个文字都是责任，每句话都是证据！如果某事没有被记录，即等于没有发生。只有被准确、及时记录下来的护理行为，才能被承认和追溯。

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  1. CONNECT:[ UseTime:0.000680s ] mysql:host=172.18.0.4;port=3306;dbname=h_sjds;charset=utf8mb4
  2. SHOW FULL COLUMNS FROM `fenlei` [ RunTime:0.000886s ]
  3. SELECT * FROM `fenlei` WHERE `fid` = 0 [ RunTime:0.000416s ]
  4. SELECT * FROM `fenlei` WHERE `fid` = 63 [ RunTime:0.000373s ]
  5. SHOW FULL COLUMNS FROM `set` [ RunTime:0.000599s ]
  6. SELECT * FROM `set` [ RunTime:0.000280s ]
  7. SHOW FULL COLUMNS FROM `article` [ RunTime:0.000577s ]
  8. SELECT * FROM `article` WHERE `id` = 578210 LIMIT 1 [ RunTime:0.000351s ]
  9. UPDATE `article` SET `lasttime` = 1794075430 WHERE `id` = 578210 [ RunTime:0.001294s ]
  10. SELECT * FROM `fenlei` WHERE `id` = 64 LIMIT 1 [ RunTime:0.000353s ]
  11. SELECT * FROM `article` WHERE `id` < 578210 ORDER BY `id` DESC LIMIT 1 [ RunTime:0.000418s ]
  12. SELECT * FROM `article` WHERE `id` > 578210 ORDER BY `id` ASC LIMIT 1 [ RunTime:0.000385s ]
  13. SELECT * FROM `article` WHERE `id` < 578210 ORDER BY `id` DESC LIMIT 10 [ RunTime:0.000517s ]
  14. SELECT * FROM `article` WHERE `id` < 578210 ORDER BY `id` DESC LIMIT 10,10 [ RunTime:0.000467s ]
  15. SELECT * FROM `article` WHERE `id` < 578210 ORDER BY `id` DESC LIMIT 20,10 [ RunTime:0.000665s ]
0.096416s