医护病程录一体化书写的研究与应用  

Study of All-In-One Writing Model of Medical Record

作　　者：金其林[1] 奚从华[1] 郑丽芬[1] 矛丽娟[1] 

机构地区：[1]上海市杨浦区中心医院,上海200090

出　　处：《中国卫生质量管理》2006年第3期17-19,共3页Chinese Health Quality Management

摘　　要：目的探索符合现代医院管理和提高医疗质量要求的病案书写新模式；方法设计“医护病程录一体化”新的书写模式,并与老模式比较,用EXCEL和SPSS11．0软件进行统计分析；结果医护病程录一体化提高了医护记录内容的一致率(P＜0．05)；结论医护病程录一体化有利于医疗质量的提高。Objective To explore a new model of medical report in accordance with the requests of modern hospital management and advances on medical treatment quality. Methods To design an all - in - one writing model of medical record between mediacal treatment and nursing during the course of diseases care with a comparison of the old one, using EXCEL and SPSS 11.0 for statistical analysis. Results All - in - one medical care report improves the consistent of the content in medical care records. （ p 〈0.05 ）. Conclusions All - in - one medical care report makes for the inprovement of medical care quality.

关 键 词：病程记录 医护一体化 医疗质量 

分 类 号：R47[医药卫生—护理学] R197.323[医药卫生—临床医学]