护理记录全程质量管理的做法与效果  

Practice and effects of the whole quality control of nursing records

作　　者：田丽亚[1] 张晓燕[1] 薛兰枝[1] 

机构地区：[1]内蒙古医学院附属医院病案室,呼和浩特市010050

出　　处：《护理管理杂志》2010年第4期271-272,共2页Journal of Nursing Administration

摘　　要：目的规范护理文件书写,提高护理记录书写质量。方法通过组建三级护理记录质量管理组织、强化护理人员的法制教育、建立护理记录全程质量管理体系的措施,对护理记录基础质量、终末质量和环节质量进行控制。结果实施护理记录全程质量管理后护理记录质量明显提高,医疗纠纷发生率下降,护理人员的满意度提高。结论护理文书管理必须强调全程化,是实现护理质量全面提高的重要内容。Objective To standardize nursing records writing and improve the quality of nursing reeords. Methods The measures included establishing a three - level special organization to manage the quality of nursing records, strengthening the legal education among nursing staff, and developing specific measures to manage the whole course of recording in order to control the basic quality,terminal quality, and links quality of nursing records. Results The quality of nursing records was improved obvlously,the incidence of medical disputes decreased, and nurses satisfaction increased of nursing. Conclusion The management of nursing documents should emphasize the whole course control ,which is the main method to improve the quality.

关 键 词：护理文书 质量管理 护士 

分 类 号：C931.2[经济管理—管理学]