中医医院护理文书质量评价指标体系的建立与应用  

Construction of A Quality Evaluation System for Nursing Documents in TCM Hospital and Its Application

作　　者：李平[1] 牟善芳[2] 冯凤[3] 翟燕[4] 谢彩霞[5] 荆淑红[6] 

机构地区：[1]山东中医药大学附属医院护理部,山东济南250011 [2]山东中医药大学附属医院妇科,山东济南250011 [3]山东中医药大学附属医院急诊科,山东济南250011 [4]山东中医药大学附属医院骨,山东济南250011 [5]山东中医药大学附属医院免疫内科,山东济南250011 [6]山东中医药大学附属医院肛肠科,山东济南250011

出　　处：《护理学杂志》2009年第4期1-3,共3页

基　　金：山东省中医药科技发展计划项目(2007-097)

摘　　要：目的建立实用的中医医院护理文书书写质量评价指标体系(下称指标体系),为护理文书质量管理提供评价标准和改进依据。方法在回顾文献和典型调查的基础上起草指标体系;运用德尔菲法函询论证,确定指标体系并应用于临床,连续6个月后评价应用指标体系前后护理文书书写质量。结果指标体系包括要素质量(20分)、环节质量(60分)及终末质量(20分)3个维度(共9项一级指标,30项二级指标),每个维度扣分≥10%为不合格。指标体系实施后护理文书书写要素质量、环节质量、终末质量合格率显著高于实施前(均P<0.01)。结论指标体系实用、合理,有利于中医医院护理文书书写质量的提高和持续改进。Objective To construct a scientific, practicable quality evaluation system for nursing documents in TCM hospital, and to provide reference for quality appraisal of nursing document. Methods Literature review, representative survey, and Delphi approach were employed to build the system. After 6 months＇ clinical application, the quality of nursing documents was compared. Results The quality evaluation system was composed of 3 dimentions, namely essential factor quality （20 points）, process quality （60 points） and outcome quality（20 points）, with 9 level 1 indicators and 30 level 2 indicators, and more than 10% points deducted from each dimension was considered to be disqualified. The quality of the 3 dimensions of nursing documents showed statistical differences before and after its application （P〈0.01 for all）. Conclusion The quality evaluation system for nursing documents in TCM hospital is practicable and reasonable, and it can promote the quality of nursing documents.

关 键 词：中医医院 护理文书 评价指标体系 DELPHI法 护理管理 

分 类 号：R248[医药卫生—中医临床基础] C931.3[医药卫生—中医学]