2021年第三季度歸檔病歷護(hù)理質(zhì)量評(píng)分表[復(fù)制]檢查人員[單選題]○何麗莉○莫占端○童麗靈○黎福理○王輝微○王海燕○陳春華○陳曉虹○王秀波○陳丹丹○梁梅蘭○林海麗○王小霞○安學(xué)芳○王玉娟○吳紀(jì)萍○林玲○陳?？剖遥篬填空題]_________________________________住院號(hào)：[填空題]_________________________________住院天數(shù)：[填空題]_________________________________一、體溫單不漏項(xiàng)[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________入院、出院、死亡、轉(zhuǎn)科的填寫符合要求[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________血壓、體重、身高、出入量等記錄符合要求[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________與實(shí)際病情相符[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________與護(hù)理記錄單填寫一致[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________二、醫(yī)囑單藥物試驗(yàn)皮試結(jié)果有記錄[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________三、入院（?？疲┰u(píng)估單不漏項(xiàng)、評(píng)估完整(具體描述)。[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________與醫(yī)生一致（疾病史、飲酒史、吸煙史、手術(shù)史、過敏史、其他）[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________四、ADL評(píng)估不漏項(xiàng)[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________病情變化或自理能力發(fā)生變化隨時(shí)有評(píng)估[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________評(píng)估結(jié)果與病情相符[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________五、疼痛護(hù)理疼痛評(píng)估工具選擇正確、結(jié)果正確[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________評(píng)估與再評(píng)估及時(shí)準(zhǔn)確[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________記錄符合要求（包括疼痛部位、性質(zhì)、程度、相關(guān)因素、措施及結(jié)果、宣教）[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________六、跌倒評(píng)估單不漏項(xiàng)[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________病情發(fā)生變化隨時(shí)有評(píng)估[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________評(píng)估正確[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________七、壓瘡評(píng)估單不漏項(xiàng)[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________發(fā)生變化隨時(shí)有評(píng)估[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________評(píng)估正確[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________八、壓瘡記錄單不漏項(xiàng)[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________發(fā)生變化隨時(shí)評(píng)估[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________評(píng)估正確[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________九、管道評(píng)估記錄單不漏項(xiàng)[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________發(fā)生變化隨時(shí)評(píng)估[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________評(píng)估正確[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________十、深靜脈血栓評(píng)估單[單選題]○選項(xiàng)1○選項(xiàng)2評(píng)估結(jié)果與病情相符[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________發(fā)生變化隨時(shí)有評(píng)估[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________十一、健康教育單填寫完整，不漏項(xiàng)[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________教育要及時(shí)、連續(xù)、體現(xiàn)?？铺攸c(diǎn)[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________十二、血糖單不漏項(xiàng)[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________十三、轉(zhuǎn)科交接單。不漏項(xiàng)，簽名完整[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________十四、護(hù)理記錄單護(hù)理記錄應(yīng)客觀、真實(shí)、準(zhǔn)確、及時(shí)、完整；表述準(zhǔn)確、語句通順、運(yùn)用醫(yī)學(xué)術(shù)語、無主觀臆斷、記錄無錯(cuò)漏,不重復(fù)、無缺頁、即時(shí)記錄[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________特殊治療、用藥、搶救等應(yīng)有開始和結(jié)束時(shí)間、療效記錄、手術(shù)病人有術(shù)前晚睡眠情況記錄[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________危急值有病情觀察、護(hù)理措施、效果評(píng)價(jià)[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________搶救結(jié)束6小時(shí)內(nèi)有搶救記錄[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________十五、手術(shù)記錄單手術(shù)安全核查表、手術(shù)清點(diǎn)記錄、手術(shù)交接記錄單填寫完整[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________滅菌效果監(jiān)測(cè)指示卡或內(nèi)植物標(biāo)識(shí)按要求粘貼[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________十六、輸血記錄單配血、輸血記錄單填寫完整[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________出現(xiàn)輸血反應(yīng)等異常情況時(shí)有病情觀察、護(hù)理措施、效果評(píng)價(jià)[多選題]□缺陷個(gè)數(shù)_________________□詳細(xì)描述_________________十七、其他打印字跡清晰[多選題]□缺陷個(gè)數(shù)______