胸外科病情护理记录单书写缺陷原因分析与质控对策  

Causes Analysis and Quality Control Countermeasures for Defects in Nursing Records of Thoracic Surgery Cases

作　　者：宋金美[1] 应华娟[1] 朱莉萍 SONG Jin-mei;YING Hua-juan;ZHU Li-ping(Shaoxing Second Hospital)

机构地区：[1]绍兴第二医院

出　　处：《医院管理论坛》2020年第8期44-45,49,共3页Hospital Management Forum

摘　　要：目的总结胸外科电子病情护理记录单存在的缺陷,分析原因,提出相应质控对策。方法选取251份肺部手术治疗患者的电子病情护理记录单在归档前进行书写缺陷总结,调查护士对书写缺陷的原因分析。结果电子病情护理记录单缺陷高达79.9%。护士认为护理文书书写量多,工作量大,专业知识欠缺,实时质量管理不到位是主要原因。结论提高护士自身专业素养,科室严格落实三级实时质控制度,减少护理文书书写量,医院保障合适床护比及多部门合作,提高电子病情护理记录单内涵质量。Objective To summarize the defects of the electronic nursing records of thoracic surgery,analyze the reasons,and put forward corresponding quality control measures.Methods 251 electronic nursing records of patients undergoing lung surgery were selected to summarize the writing defects before filing,and the nurses were investigated to analyze the causes of writing defects.Results The defects of the electronic nursing care records were as high as 79.9%.Nurses believed that the main reasons were the large amount of nursing writing,heavy workload,lack of professional knowledge,and inadequate real-time quality management.Conclusion It is needed to improve the professionalism of nurses,strictly implement the three-level real-time quality control system in the department,reduce the amount of nursing writing,ensure an appropriate bed-to-care ratio and multi-departmental cooperation in the hospital,and improve the content quality of the electronic nursing records.

关 键 词：病情记录 书写缺陷 质控对策 内涵质量 

分 类 号：R192.6[医药卫生—卫生事业管理]