RICU危重患者护理文书管理中品管圈的应用效果  

Application of QC Circle in RICU Critically Ill Patients Nursing Medical Record Documents

作　　者：席建宏[1] 向启娥 董正惠[3] Xi Jianhong;Xiang Qi＇ e;Dong Zhenghui(The First Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, Xinjiang, Chin)

机构地区：[1]新疆医科大学第一附属医院呼吸危重症中心RICU,乌鲁木齐市830000 [2]新疆墨玉县人民医院,墨玉县848100 [3]新疆医科大学第一附属医院护理部,乌鲁木齐市830000

出　　处：《中国病案》2018年第4期17-19,共3页Chinese Medical Record

基　　金：2015年新疆医科大学人文社科基金项目(2015XYDSK21)

摘　　要：目的探讨品管圈(QCC)应用于呼吸重症监护室病房(RICU)护理文书管理的效果。方法在RICU成立品管圈活动小组,选定提高危重患者护理文书质量及归档率为主题,通过对2016年第二季度护理文书的质控情况进行调查分析,了解RICU护理文书存在的问题,分析原因,制定整改措施,开展品管圈活动。结果实施品管圈活动后,RICU危重患者护理文书甲级率高于干预前,丙级率低于干预前,差异有统计学意义(P<0.05),而乙级率无统计学差异;干预后病案三日归档率高于干预前,差异有统计学意义(P<0.05)。结论品管圈在科室危重患者护理文书管理中效果显著,明显提高了科室护理文书质量及归档率,推动科室护理文书管理的持续改进,值得推广应用。Objective To explore the effect of QCC in the management of nursing documents in the respiratory intensive care unit（RICU）. Methods Set up quality control circle activities section in RICU, selected to improve the nursing care of critical patients quality of medical documents and filing rate as the theme. Through the investigation and analysis of the quality control of nursing documents in the second quarter of 2016, we can understand the problems in RICU nursing documents, analyze the causes, formulate corrective measures, and carry out QCC. Results After the implementation of t QCC, the rate of Grade A of nursing case of critical patients in RICU is higher than that before intervention, the medical record rate C is lower than before the intervention, the difference was statistically significant（P〈0.05）, there was no statistical difference in the rate of medical records in Grade B; The three day filing rate of nursing documents was higher than that before intervention, the difference was statistically significant（P〈0.05）. Conclusion The effect of QCC in the Department of medical record management in nursing care of critical patients significantly, significantly improve the nursing quality of the medical record and filing rate, promote the continuous improvement of medical record management in the Department of nursing, it is worthy of popularization and application.

关 键 词：品管圈 病案质量 护理文书 归档率 

分 类 号：R47[医药卫生—护理学]