护理病历质量监控的探讨  

Discussion on the Quality Monitoring of Nursing Medical Records

作　　者：陈冬连[1] 朱艳艳[1] 龚黛琛[1] 洪雅君[1] 苏静[1] 

机构地区：[1]中国人民解放军第174医院

出　　处：《中国病案》2014年第7期16-17,共2页Chinese Medical Record

摘　　要：目的通过对3个护理病区的分组检查和比较,分析病案缺陷的原因并采取整改措施,提高护理病历书写质量。方法抽查2013年1月-12月三个护理病区1450份出院病案,应用SPSS11.0统计软件进行数据统计处理。结果 1450份出院病案中查出缺陷病案共计237份,缺陷率17.8%。结论通过采取有效检查及干预措施,从源头把关,护理病案缺陷率下降,提高了护理文书书写质量,避免了医疗纠纷的发生。Objectives To analyze the reason of the medical record defects and take corrective actions through the grouping inspection and comparison of three nursing wards,and improve the quality of nursing records writing.Methods 1450 cases of discharged medical records in three nursing wards from January 2013 to December 2013 were inspected,and conducted data statistics processing with SPSS 11.0 statistical software.Results 237 cases of defects medical records were selected from the 1450 discharged medical records,the defect rate was 17.8％.Conclusions With the application of effective inspection and intervention measures and control from source,the defect rate of nursing records fell to 7.9％,improved the quality of the nursing documents writing,and avoided the occurrence of medical disputes.

关 键 词：分组检查 常见缺陷 控制措施 

分 类 号：R47[医药卫生—护理学]