病历书写督导员对改善低年资护士电子病历书写质量的作用  

Effect evaluation of electronic medical record quality of junior nurses with supervision by medical record writing supervisor

作　　者：沈玉萍[1] 汤菊萍[1] 

机构地区：[1]杭州市第三人民医院,浙江杭州310009

出　　处：《浙江医学教育》2017年第4期30-31,17,共3页Zhejiang Medical Education

摘　　要：目的:探讨病历书写督导员干预对低年资护士电子病历书写质量的影响。方法:按照随机数字表法选取我院2014年8-12月未实施病历书写督导员进行督导的低年资护士电子病历460份和2015年1-5月实施病历督导员进行督导的低年资护士电子病历460份。按照浙江省《病历书写规范》的有关规定,以诊疗护理规范和护理常规作为主要评价标准,对护理电子病历进行缺陷记录,比较实施前后电子病历质量的差异。结果:实施病历书写督导员进行督导的低年资护士电子病历书写缺陷率(12.6%)明显低于实施前的缺陷率(36.7%)(P<0.05)。结论:病历书写督导员对低年资护士电子病历书写质量的提升有积极的促进作用,有效减少了低年资护士病历书写缺陷,提升了电子病历质量,在保证护理安全的同时提高了护理管理质量。[ Objection] To study the effect of improvement of electronic medical record quality of junior nurses with the supervision by medical record writing supervisor. [Method] 460 electronic medical records written by junior nurses from August to December in 2014 without the supervision by medical record writing supervisor, were selected as control group. Another 460 records written by junior nurses from January to May in 2015 with the supervision by medical record writing supervisor were selected as observation group. The defects of these records were record and the quality differences were compared between the two groups. [ Result] The defect rate （12.6%） of electronic medical record in observation group was obviously less than that （ 36.7 % ） of the control group. [ Conclusion] Medical record writing supervisor has a positive role in promoting junior nurses＇ electronic medical record quality, reducing writing defects, improving the quality of electronic medical records. It can guarantee nursing safety and improve the quality of nursing management.

关 键 词：病历书写督导员 低年资护士 电子病历质量 

分 类 号：R192.2[医药卫生—卫生事业管理]