危重患者护理记录书写质量分析及对策  

Quality Analysis of Nursing Record Sheets Writing of Critical Patients and Its Countermeasure

作　　者：谢小燕[1] 马军华[1] 刘茂英[1] 张丽娟[1] 

机构地区：[1]第三军医大学西南医院质控科,重庆市400038

出　　处：《中国病案》2013年第1期31-32,共2页Chinese Medical Record

摘　　要：目的分析危重患者护理记录书写质量,旨在改进护理记录质控措施,提高护理记录书写质量。方法 2010实施终末质控的护理记录质量与2011年实施环节质控加终末质控的护理记录质量进行比较,并应用PDCA循环对护理记录质量进行管理,比较护理记录缺陷率的变化。结果改进质控措施后,护理记录缺陷率有较显著下降,500例中的缺陷数由524减少为319,减少了39%,护理记录书写质量得到显著提高。结论建立健全有效的实时质控管理措施和培训检查制度是提高护理记录质量的关键。Objective To improve quality control measures of nursing record sheets, and improve the quality of nursing record sheets writing by an- alyzing writing quality of nursing record sheets of critical patients. Methods Comparing with terminal quality control in2010 to the nursing record sheets with link quality control and terminal quality control in 2011. Manage nursing record sheets quality with PDCA circulation, and compare changes of the defect rate of nursing record sheets. Results The defect rate of nursing record sheets has a significant decline after improving quality control measures. The number of defects reduced from 524 to 319, decreased by 39%. The writing quality of nursing record sheets has a significant improvement. Cam. dusion Establish and perfect the effective real-time quality control management measures and training inspection system is the key to improve the quality of nursing record sheets.

关 键 词：护理记录书写 质控 终末质控 全程质控 

分 类 号：R47[医药卫生—护理学]