护理质量监控对终末护理病历质量的影响探讨  

Effect of nursing care quality monitoring on terminal quality of nursing records

作　　者：刘秋英 

机构地区：[1]广西壮族自治区脑科医院,广西柳州545005

出　　处：《医药前沿》2015年第6期110-111,共2页Journal of Frontiers of Medicine

摘　　要：目的：探讨临床护理工作中护理质量监控对终末护理病历质量的影响。方法：选取我院2012年7月-2014年1月实施护理病历质量监控前后的病历各500份，并对实施护理质量监控前后病历等级评价、病历缺陷情况以及病历返修情况进行对照，分析和探讨护理质量监控对终末护理病历质量的影响。结果：在实行护理质量监控后终末护理病历质量水平明显提高，各项护理质量检查成绩平均分从之前的93．32分上升到现在的98．86分（各项标准分100分）；在实行护理质量监控后，护理病历各项项目的缺陷率和返修率均出现大幅降低，差异具有统计学意义（P〈0．05）。结论：在医院临床护理工作中，实施护理质量监控对终末护理病历质量具有积极影响，护理质量有显著提升，护理管理质量和效率也大大提高。Objective Effect of nursing care quality monitoring on terminal quality of nursing records. Methods Selected from July 2012 to January 2014 the implementation of nursing before and after the medical records of all 500 medical record quality monitoring and medical record ratings before and after the implementation of nursing quality control, case defects and repair situation comparison, analysis and discussion on nursing quality control on the quality of terminal care medical records. Results After nursing quality surveillance terminal care medical records quality improved obviously, the nursing quality check grade average, up from 93.32 points before now 98.86 points （the standard score 100 points）; After practice the nursing quality control, nursing medical records all the defect rate and repair rate greatly reduced, the difference has statistical significance （P 〈 0.05）. Conclusions In hospital clinical nursing work, the implementation of nursing quality control has a positive influence on quality of terminal care medical records, nursing quality has significantly increased, the nursing management quality and efficiency are greatly improved.

关 键 词：护理质量监控 终末护理病历 影响 

分 类 号：R471[医药卫生—护理学]