品质圈活动在提高护理病历书写质量中的应用  

Applying QC activity in improving nursing quality on medical record

作　　者：邓少芳[1] 邓桂芳[1] 黄英群[1] 冯丽珍[1] 

机构地区：[1]珠海市人民医院外二科,519000

出　　处：《现代护理》2006年第24期2330-2331,共2页Modern Nursing

摘　　要：目的探讨护理病历书写存在的问题与对策。方法采用品质圈(QC)活动方法和步骤,采用头脑风暴法对护理病历存在的问题进行原因分析,制定对策,继而实施对策,评价效果,建立制度。结果随机抽查100份病历,缺陷处从活动前417处降至活动后83处。结论通过QC活动使护理人员自觉利用业余时间参与法律知识、病历书写规范、医德医风、专业技能培训,自觉遵守质控奖惩办法,从而达到“有错则改”的目的,确保了护理病历的书写质量。Objective To explore the problems of nursing records and the measurements. Methods Quality circle（QC） activity and steps and ＂brainstorm＂ methods were used to analyze the problems of nursing records. Then framed the procedures to deal with them, evaluated the effect, and established effective system. Results The number of faulty cases in 100 medical records which were randomly sampled dropped from 417 to current 83 faults. Conclusions The program of QC has urged the nursing staff making used of spare-time to voluntarily participate in the training on legal basics, medical record criterion , medical attitude, and specialty skills. So the nursing quality of medical record is improved.

关 键 词：质量控制 护理病历 品质圈(QC) 

分 类 号：R47[医药卫生—护理学]