第三季度护理归档病历质控附有答案

2023年第三季度护理归档病历质控[复制]1.检查人员[单选题]○何丽莉○陈丹丹○黎福理○王小霞○吴纪萍○陈晓虹○王辉薇○王海燕○吴玉丹○林海丽○陈春华○潘妙霞○梁梅兰○潘德萍○王玉娟○选项107○选项1082.住院天数：[填空题]*_________________________________3.科室：[填空题]*_________________________________4.住院号：[填空题]*_________________________________5.满分[填空题]*_________________________________一、入院/转科评估单。6.无漏项、评估完整（具体描述）。[多选题]□缺陷个数_________________□详细描述_________________7.医护一致（疾病史、饮酒史、吸烟史、手术史、过敏史、其他）[多选题]□缺陷个数_________________□详细描述_________________二、转交接单。8.无漏项，签名完整[多选题]□缺陷个数_________________□详细描述_________________三、跌倒评估单9.无漏项[多选题]□缺陷个数_________________□详细描述_________________10.病情发生变化随时有评估[多选题]□缺陷个数_________________□详细描述_________________11.评估正确[多选题]□缺陷个数_________________□详细描述_________________四、ADL评估单12.无漏项[多选题]□缺陷个数_________________□详细描述_________________13.病情变化或自理能力发生变化随时有评估[多选题]□缺陷个数_________________□详细描述_________________14.评估结果与病情相符[多选题]□缺陷个数_________________□详细描述_________________五、管道评估记录单15.无漏项[多选题]□缺陷个数_________________□详细描述_________________16.发生变化随时评估[多选题]□缺陷个数_________________□详细描述_________________17.评估正确[多选题]□缺陷个数_________________□详细描述_________________六、压疮评估单18.无漏项[多选题]□缺陷个数_________________□详细描述_________________19.发生变化随时评估[多选题]□缺陷个数_________________□详细描述_________________20.评估正确[多选题]□缺陷个数_________________□详细描述_________________七、压疮记录单21.无漏项[多选题]□缺陷个数_________________□详细描述_________________22.发生变化随时评估[多选题]□缺陷个数_________________□详细描述_________________23.评估正确[多选题]□缺陷个数_________________□详细描述_________________八、疼痛评估单24.疼痛评估工具选择正确、结果正确[多选题]□缺陷个数_________________□详细描述_________________25.评估与再评估及时准确[多选题]□缺陷个数_________________□详细描述_________________26.记录符合要求（包括疼痛部位、性质、程度、相关因素、措施及结果、宣教）[多选题]□缺陷个数_________________□详细描述_________________九、体温单27.无漏项[多选题]□缺陷个数_________________□详细描述_________________28.入院、出院、死亡、转科的填写符合要求[多选题]□缺陷个数_________________□详细描述_________________29.血压、体重、身高、出入量等记录符合要求[多选题]□缺陷个数_________________□详细描述_________________30.与实际病情相符[多选题]□缺陷个数_________________□详细描述_________________31.与护理记录单填写一致[多选题]□缺陷个数_________________□详细描述_________________十、医嘱单32.药物试验皮试结果有记录[多选题]□缺陷个数_________________□详细描述_________________十一、护理记录单33.护理记录应客观、真实、准确、及时、完整；表述准确、语句通顺、运用医学术语、无主观臆断、记录无错漏,不重复、无缺页、即时记录[多选题]□缺陷个数_________________□详细描述_________________34.特殊治疗、用药、抢救等应有开始和结束时间、疗效记录，手术病人有术前晚睡眠、术后病情观察等情况记录。[多选题]□缺陷个数_________________□详细描述_________________35.危急值有病情观察、护理措施、效果评价[多选题]□缺陷个数_________________□详细描述_________________36.抢救结束6小时内有抢救记录[多选题]□缺陷个数_________________□详细描述_________________十二、手术记录单37.手术安全核查表、手术清点记录、手术交接记录单填写完整[多选题]□缺陷个数_________________□详细描述_________________38.灭菌效果监测指示卡或内植物标识按要求粘贴

[多选题]□缺陷个数_________________□详细描述_________________十三、健康教育评估单39.填写完整、无漏项[多选题]□缺陷个数_________________□详细描述_________________40.教育及时、连续、能体现专科特点[多选题]□缺陷个数_________________□详细描述_________________十四、血糖单41.无漏项[多选题]□缺陷个数_________________□详细描述_________________42.[多选题]□缺陷个数_________________□详细描述_________________十五、深静脉血栓评估单43.深静脉血栓评估单[多选题]□缺陷个数_________________□详细描述_________________44.评估结果与病情相符[多选题]□缺陷个数_________________□详细描述_________________45.发生变化随时有评估[多选题]□缺陷个数_________________□详细描述_________________十六、输血记录单46.配血、输血记录单填写完整[多选题]□缺陷个数_________________□详细描述_________________47.出现输血反应等异常情况时有病情观察、护理措施、效果评价[多选题]□缺陷个数_________________□详细描述