护理病历书写质量控制措施效果评价  

Evaluation of Effect of Quality Control of Nursing Medical Record Writing.

作　　者：张常红[1] 唐小英[2] 徐双燕[2] 叶敏[2] 范中华[2] 

机构地区：[1]成都铁路中心医院,四川成都610081 [2]成都市第七人民医院,四川成都610041

出　　处：《四川省卫生管理干部学院学报》2007年第3期211-212,共2页Journal of Sichuan Continuing Education College of Medical Sciences

摘　　要：目的:实施护理病历书写质量控制措施,提高护理病历书写质量,体现护理记录真实、客观、准确、及时和完整性。方法:对质控措施实施前后各连续抽取的1500份护理病历,行护理病历书写缺陷项目量测评并比较。结果:实施质控措施后护理病历缺陷项目量明显减少(t=0.003),书写质量提高。结论:质控措施是保证医院护理病历书写质量的必备要件。Objectives Through implementing quality control measures of nursing medical records writing to improve the quality of nursing medical records writing, which makes them reflect the truth, objective, accuracy, timely and integrity. Methods Before and after the implementation of quality control measures, we sampled 1500 nursing medical records. The defect items in the nursing medical records were measured and compared. Results After the implementation of quality control measures, the number of defect items decreased significantly （t = 0.003） and the quality of writing was improved. Conclusions The quality control measures are essential elements to ensure the quality of nursing medical records.

关 键 词：护理病历书写 质量 控制 措施 

分 类 号：R575.5[医药卫生—消化系统]