科室建立三级质控在护理文件书写质量中的应用  

Application of department establishment of three-level quality control in quality of nursing document writing

作　　者：张丽[1] 赵猛超[1] 侯佳[1] 赵明娟[1] 

机构地区：[1]河北省儿童医院普外科,石家庄市050031

出　　处：《护理实践与研究》2016年第15期117-119,共3页Nursing Practice and Research

摘　　要：目的：探讨科室建立并实施三级质量控制在护理文件书写质量中的应用效果。方法：随机抽取2014年1-12月出院的1095份病例作为对照组，随机抽取2015年1～12月出院的1095份病历作为观察组。对照组由负责护理文件质控小组进行质量控制，各尽其责；观察组除上述方法外，建立并实行了三级质量控制，细化了质控流程，加强环节和终末质量控制。比较两组检查结果。结果：观察组护理文件书写质量高于对照组（P〈0．05），各种缺陷率均低于对照组（P〈O．05）。结论：科室建立并实施三级质控管理小组以来，细化了质控的流程，各环节紧密把关，严格质量控制，做好信息反馈，是全面提高护理文件书写质量的有效管理方法。’Objective： To explore the application effects of department establishment and implementation of three - level quality control in quality of nursing document writing. Methods：Randomly sdected 1095 patients discharging during January 2014 - December 2014 as control group, randomly selected 1095 patients discharging from January 2015 to December 2015 as observation group. The control group conducted quality control by quality control group in charge of nursing documents and played their roles respectively; besides adopting the methods above, the observation group established and implemented three - level quality control, refined quality control processes, strengthened link and ending quality control. Compared the test results of the two groups. Re- suits ： the observation group＇ s quality of nursing document writing was higher than that og the control group （ P 〈 0.05 ）, all defect rates were lower than those of the control group （ P 〈 0.05 ）. Conclusion ： Since the department established and carried out three - level quality control management group, the de- partment has refined processes of quality control, closely checked all links, strictly controlled quality and done well in information feedback. It is an effec- tive management method to comprehensively improve the quality of nursing documents writing.

关 键 词：三级质控 质量管理 护理文件 

分 类 号：R47[医药卫生—护理学]