全员参与护理记录质量管理效果分析  

Full participation in the quality of nursing records management effectiveness analysis

作　　者：潘红英[1] 施建英[2] 陈嘉凤[3] 

机构地区：[1]浙江省丽水市中心医院外科,浙江丽水323000 [2]浙江省丽水市中心医院院长办公室,浙江丽水323000 [3]浙江省丽水市中心医院内科,浙江丽水323000

出　　处：《中国现代医生》2012年第31期122-123,共2页China Modern Doctor

基　　金：浙江省丽水市科技局2009年资助课题(丽科[2009]61号)

摘　　要：目的提高护理记录质量。方法护理部成立"全员参与护理记录质量管理"管理小组,动员病区护士全员参与护理记录质量控制,护士可根据自己意愿分别参加质量控制组和教学科研组。结果护理记录检查得分明显高于全员参与质量控制前,差异有统计学意义(P﹤0.01);有效简化了护理记录的书写,完善了护理记录书写细则;快速推广了护理电子病历。结论全员参与能有效提高护理记录质量;要注重护士参与质量的控制和提高护士的主动参与的积极性。Objective To improve the quality of nursing records. Methods The care team was established that the ＂full participation in the quality of nursing records＂management the management team to mobilize the ward nurses to full partici- pation in the quality of nursing records control nurses according to their wishes to participate in the quality control group, teaching and research group. Results Nursing records check score significantly higher than the full participation of quality control before there was significant difference（P 〈 0.01 ） ;simplifies the writing of nursing records, and to improve the nurs- ing record details;rapid promotion of care electronic medical records. Conclusion Full participation can effectively improve the quality of nursing records;to pay attention to the nurses participating in quality control and improve the nurse＇s active participation in the positive.

关 键 词：质量管理 参与 护理记录 

分 类 号：R47[医药卫生—护理学]