加强护理文件书写质量控制和管理措施的探讨  

Probe into the measures to improve quality control and management of nursing documents

作　　者：陈相平[1] 张桂琴[1] 

机构地区：[1]四川省自贡市第一人民医院护理部,643000

出　　处：《护理实践与研究》2010年第11期57-59,共3页Nursing Practice and Research

摘　　要：目的:通过对护理文件书写缺陷分析,探讨护理文件书写质量控制和管理措施,持续提高护理文件书写质量。方法:2008年护理部每月随机抽取每科上月归档病历5份进行终末质量考核,全年共抽取1200份作为对照组,每月将考核结果进行统计分析,针对缺陷的原因,采取了为期1年的加强护理文件质量控制和管理措施后,2009年再用同样的方法随机抽取归档病历1200份作为观察组进行终末质量考核,将两组考核结果进行比较。结果:2009年护理文件书写质量比2008年有明显提高(P<0.05),各项护理文件的缺陷率明显低于2008年(P<0.01)。结论:规范护理文件书写标准,加强相关知识培训,严格质量控制,做好信息反馈,制定奖惩制度,可提高护理文件书写质量。Objective：By analyzing the defects existing in the nursing documents,we want to work out the measures to improve quality control and management of nursing documents continuously.Methods：Every month in 2008,the nursing department randomly drew 5 samples of the filed medical records of every clinical department to make terminal quality assessment,and totally 1200 samples were drawn as the control group throughout the year.According to monthly statistical analysis of the results and the causes of the defects,we took measures to improve nursing documents quality control and management for one year.In the same way,in 2009,we randomly drew 1200 samples of the filed medical records as observation group to make terminal quality assessment and compared the assessment results of the 2 groups.Results：The document writing quality in 2009 was better than that in 2008 obviously（P0.05）.The rate of defects in 2009 was obviously lower than that in 2008（P0.01）.Conclusion：The following are the measures that can help to improve nursing documents writing quality：standardizing nursing document forms,strengthening related writing training,strict quality management,information feedback,establishing a system of rewards and penalties.

关 键 词：护理文件 质量控制 管理措施 

分 类 号：R47[医药卫生—护理学]