重症护理文书质量控制信息反馈系统的设计与应用  

Design and application of information feedback system for quality control of intensive care documents

作　　者：王密芳[1] 张飞飞[1] 李爱丹[1] 闵小彦[1] 黄凡[1] 沙芬芳[1] 张丽萍[1] WANG Mifang;ZHANG Feifei;LI Aidan;MIN Xiaoyan;HUANG Fan;SHA Fenfang;ZHANG Liping(ICU,the Second Affiliated Hospital of Wenzhou Medical University,Wenzhou 325027,China)

机构地区：[1]温州医科大学附属第二医院重症医学科,温州市325027

出　　处：《护理管理杂志》2021年第4期301-304,共4页Journal of Nursing Administration

基　　金：浙江省温州市科技局科研项目(Y20190309)。

摘　　要：目的建立重症护理文书质量控制信息反馈系统,探讨其在临床中的应用效果。方法由护士与计算机工程师共同设计建立重症护理文书质量控制信息反馈系统,通过质量检查、信息确认及反馈、质量分析与整改、质量控制的步骤实施重症护理文书质量控制,比较系统应用前后终末重症护理文书质量控制得分、质量控制问题未修改发生率以及质量控制结果统计分析平均用时。结果应用重症护理文书质量控制信息反馈系统后,与原来的质量控制信息纸质登记并手工统计模式相比,终末重症护理文书质量控制得分从(91.19±2.72)分提高至(94.96±1.83)分,质量控制问题未修改发生率从17.64%下降至4.65%,质量控制平均用时从(3.84±0.38)h下降到(1.79±0.19)h,差异均有统计学意义(P<0.01)。结论重症护理文书质量控制信息反馈系统是保证护理文书书写质量的有效手段,提高了质量控制效率和质量控制水平,提升了护理管理信息化水平。Objective To establish the information feedback system for quality control of intensive care documents,and to explore its clinical effects of application.Methods The information feedback system for quality control of intensive care documents was designed by nurses and computer engineers.Through the steps of quality inspection,information confirmation and feedback,quality analysis and rectification,and quality control to implement the quality control.Then compared the quality control scores of the beginning and final intensive care documents,the incidence of unmodified quality control problems and the average time for statistical analysis of quality control results.Results After the application of the information feedback system for quality control of intensive care documents,the quality control score of the final intensive care documents increased from(91.19±2.72)to(94.96±1.83),the incidence of unmodified quality control problems decreased from 17.64%to 4.65%,and the average time for quality control decreased from(3.84±0.38)h to(1.79±0.19)h,with statistically significant difference(P<0.01).Conclusion The information feedback system for quality control of intensive care documents is an effective means to guarantee the writing quality of nursing documents,improve the quality control efficiency and quality control level,and improve the information level of nursing management.

关 键 词：信息系统 质量控制反馈 重症护理文书 质量管理 

分 类 号：R47[医药卫生—护理学]