基于帕累托法的终末护理病案质量监控  

Research on Quality Control of Nursing Medical Records Based on Pareto Principle

作　　者：张以梅[1] 王晓军[1] 杨军华[1] 宋菲 曾跃萍[1] Zhang Yimei;Wang Xiaojun;Yang Junhua;Song Fei;Zeng Yueping(Department of Medical Records Management,Beijing Children's Hospital Affiliated to Capital Medical University,National Center for Children's Health,Beijing 100045,China;不详)

机构地区：[1]国家儿童医学中心首都医科大学附属北京儿童医院,北京市100045

出　　处：《中国病案》2021年第9期7-10,共4页Chinese Medical Record

摘　　要：目的探讨运用帕累托法则对降低护理病案缺陷发生率提高终末护理病案质量的效果。方法随机抽取2019年11月1日-2020年1月31日终末护理病案1143份,作为第一阶段进行终末质控,将存在的147条问题运用帕累托法则进行归类分析,确定影响终末护理病案质量的主要问题,进行有针对性的持续改进;再随机抽取2020年5月1日-7月31日终末护理病案1143份,作为第二阶段进行质控,通过统计学分析比较第一阶段发现的主要问题在2个阶段的缺陷发生率,评价改进效果。结果通过运用帕累托法则归纳分析第一阶段终末病案质控发现的主要问题有12类缺陷类别,其中护理记录单中有创操作后护理措施描述不清楚、入院护理评估单过敏史评估与医师病案记录不一致、护理记录单离手术室时间与回病房时间记录不符、体温单入院时间与首次医嘱时间不相符4类为主要问题类别,依次占比为23.81%、22.45%、18.37,%、16.33%,累积百分比为80.96%。通过有针对性的持续改进,第二阶段再次对上一阶段的4类主要问题进行终末护理病案质控,缺陷率依次为1.74%、6.09%、2.61%、6.96%,差异有统计学意义。结论运用帕累托法则,确定影响终末护理病案质量的主要问题类别,通过有针对性的持续改进,可以有效降低终末护理病案缺陷发生率,最终提高护理文书书写质量。Objectives To explore the effect of using Pareto rule to reduce the incidence of defects in nursing medical records and improve the quality of final nursing medical records.Methods 1143 end-of-care medical records from November 1st,2019 to January 31st,2020 were randomly selected as the first stage of end-of-care quality control.147 problems were classified and analyzed using the Pareto principle to determine the main problems affecting the quality of end-of-care medical records and carry out targeted continuous improvement.Then 1143 final nursing medical records from May 1st,2020 to July 31st,2020 were randomly selected as the second stage for quality control.The defect incidence rate of the main problems in the first stage was compared in the two stages through statistical analysis to evaluate the improvement effect.Results Through the application of Pareto rule,the main problems found in the quality control of terminal medical records in the first stage were summarized and analyzed.There were 12 types of defects.Among them,in the nursing record sheet,the description of nursing measures after invasive operation was not clear,the assessment of allergy history on admission was inconsistent with the medical record of doctors,the time of leaving the operating room was inconsistent with the time of returning to the ward on the nursing record sheet,and the time of admission on the temperature sheet was inconsistent with the time of the first medical order.The proportions were 23.81%,22.45%,18.37,%,16.33% respectively,and the cumulative percentage was 80.96%.Through targeted continuous improvement,in the second stage,the quality control of the final care medical records for the four major problems in the previous stage was carried out again,and the defect rates were 1.74%,6.09%,2.61% and 6.96%,respectively,with statistically significant differences.Conclusions Using the Pareto rule to determine the main categories of problems affecting the quality of end-care medical records,through targeted continuous improvement,cou

关 键 词：护理病案 质量控制 缺陷 帕累托分析 

分 类 号：R47[医药卫生—护理学]