• 文献检索
  • 文档翻译
  • 深度研究
  • 学术资讯
  • Suppr Zotero 插件Zotero 插件
  • 邀请有礼
  • 套餐&价格
  • 历史记录
应用&插件
Suppr Zotero 插件Zotero 插件浏览器插件Mac 客户端Windows 客户端微信小程序
定价
高级版会员购买积分包购买API积分包
服务
文献检索文档翻译深度研究API 文档MCP 服务
关于我们
关于 Suppr公司介绍联系我们用户协议隐私条款
关注我们

Suppr 超能文献

核心技术专利:CN118964589B侵权必究
粤ICP备2023148730 号-1Suppr @ 2026

文献检索

告别复杂PubMed语法,用中文像聊天一样搜索,搜遍4000万医学文献。AI智能推荐,让科研检索更轻松。

立即免费搜索

文件翻译

保留排版,准确专业,支持PDF/Word/PPT等文件格式,支持 12+语言互译。

免费翻译文档

深度研究

AI帮你快速写综述,25分钟生成高质量综述,智能提取关键信息,辅助科研写作。

立即免费体验

Improving clinical documentation quality.

作者信息

Quigley P, Mathis A, Nodhturft V

机构信息

James A. Haley Veterans Affairs Medical Center, Tampa, FL.

出版信息

J Nurs Care Qual. 1994 Jul;8(4):66-73. doi: 10.1097/00001786-199407000-00011.

DOI:10.1097/00001786-199407000-00011
PMID:7919446
Abstract

A multidisciplinary documentation quality team was appointed four years ago with the charter to revise the admission nursing assessment form, eliminate the traditional handwritten nursing care plan, establish a method to utilize standards of care and standards of practice as the basis for individualizing the patient plan of care, establish flexible charting systems for specialty sections, and develop clear and concise guidelines to accompany specialty area documentation systems. This article provides an overview of the project and the outcomes realized through commitment, collaboration, and cooperation.

摘要

相似文献

1
Improving clinical documentation quality.
J Nurs Care Qual. 1994 Jul;8(4):66-73. doi: 10.1097/00001786-199407000-00011.
2
Redefine care delivery and documentation.
Nurs Manage. 2004 Feb;35(2):34-8. doi: 10.1097/00006247-200402000-00011.
3
Complying with Joint Commission nursing standards: practical documentation tools.
J Healthc Qual. 1992 Jan-Feb;14(1):24-9. doi: 10.1111/j.1945-1474.1992.tb00008.x.
4
Standardized admission and discharge templates to improve documentation of The Joint Commission on Accreditation of Healthcare Organization performance markers.标准化的入院和出院模板,以改善医疗机构评审联合委员会绩效指标的记录。
J Neurosci Nurs. 2010 Aug;42(4):225-8. doi: 10.1097/jnn.0b013e3181e26aff.
5
Interdisciplinary collaboration: strengthening documentation.跨学科合作:加强文档记录。
Nurs Manage. 1995 Oct;26(10):48L, 48N, 48P. doi: 10.1097/00006247-199510000-00015.
6
Defensible documentation using the endoscopy pathway.
Gastroenterol Nurs. 1999 Mar-Apr;22(2):38-46. doi: 10.1097/00001610-199903000-00002.
7
Improve PRN effectiveness documentation.
Nurs Manage. 2006 Sep;37(9):58. doi: 10.1097/00006247-200609000-00014.
8
Perioperative documentation. A generic or care plan.围手术期文件记录。一份通用文件或护理计划。
AORN J. 1993 Jun;57(6):1427, 1431, 1434-40.
9
An interdisciplinary documentation performance improvement project.一个跨学科的文件记录绩效改进项目。
J Nurses Staff Dev. 2004 Sep-Oct;20(5):236-41. doi: 10.1097/00124645-200409000-00008.
10
Emergency Nurse Documentation Improvement Tool.急诊护士文件记录改进工具
J Trauma Nurs. 2008 Jan-Mar;15(1):16-8. doi: 10.1097/01.JTN.0000315784.27837.ba.