藉由质控原则实施护理病历书写质量控制效果评价  

QC Effectiveness Evaluation of Nursing Record Writing by Quality Control Principle

作　　者：唐晓英[1] 张常红[2] 徐双燕[1] 范中华[1] 

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

出　　处：《现代临床医学》2008年第6期464-465,共2页Journal of Modern Clinical Medicine

摘　　要：目的:确保护理病历书写质量控制措施(质控)的有效性,以提高护理病历书写质量。方法:制定质控实施原则,对质控措施的实施进行指导,并抽取质控措施实施前后连续1 500份护理病历进行书写缺陷比较。结果:各项主要护理病历缺陷明显减少(P<0.01)。结论:质控措施应在质控的原则平台上固化实施,能更有效地实现护理病历质量的提高。Objective： To warrant the availability of the quality control （QC） for nursing record writing, to improve the quality of nursing record writing. Methods： To develop the principles and guide the practice of QC. To select 1 500 nursing records and compare the writing defects before and after the practice of QC. Results ：The main defects decreased obviously（P 〈0. 01 ）. Conclusion： QC should be practised according to QC principles, it can improve the quality of nursing record effectively.

关 键 词：护理病历 书写缺陷 质量控制 实施 原则 

分 类 号：R197.323[医药卫生—卫生事业管理]