病历阅改在护理电子病历质控中的应用效果及对护理病历书写质量的影响  

Application effect of medical record review and modification in nursing electronic medical record quality control and its influence on the quality of nursing medical record writing

作　　者：欧晓英[1] 张蕾 OU Xiaoying;ZHANG Lei(Nursing Quality Control Department,Sichuan Provincial Groups Hospital of chinese people′s Armed police Force,Leshan 614000,China)

机构地区：[1]武警四川总队医院护理质量控制科,乐山614000

出　　处：《当代护士（上旬刊）》2021年第12期183-186,共4页Modern Nurse

摘　　要：目的分析病历阅改在护理电子病历质控中的应用效果及对护理病历书写质量的影响。方法抽取2019年10月—2020年2月间本院进行护理电子病历质控的3600份病历作对照组,该阶段未进行病历阅改。抽取2020年3月—7月间本院进行护理电子病历质控的3600份病历作实验组,该阶段进行病历阅改。对比分析两组护理病历书写质量、护理病历书写缺陷发生情况及护理人员满意度。结果实验组进行病历阅改后的护理记录、体温单、首次护理记录以及医嘱单的书写质量评分均较对照组高(P<0.05);实验组首次护理记录内容漏项、病情与要求不相符、护理记录缺乏连贯性、未进行专科观察、护理措施未能有效落实、缺乏病情记录、缺乏护理反馈的发生率均比对照组低(P<0.05);实验组护理人员对差错规避、护理电子病历质控准确性及质控耗时的满意度评分均比对照组高(P<0.05)。结论在护理电子病历质控中应用病历阅改的效果显著,有助于提升护理病历书写质量,防止护理病历书写缺陷情况发生,促进护理人员满意度提高。Objective To analyze the effect of medical records review and application in nursing electronic medical record quality control and its impact on the quality of nursing medical record writing.Methods 3600 cases of medical records of our hospital for quality control of nursing electronic medical records from October 2019 to February 2020 were selected as the control group,no medical records were reviewed at this stage.3600 cases of medical records of our hospital for quality control of nursing electronic medical records from March 2020 to July 2020 were selected as the experimental group,and medical records were reviewed and modified at this stage.The quality of nursing medical record writing,the occurrence of defects in nursing medical record writing and the satisfaction of nursing staff were compared and analyzed between the two groups.Results The written quality scores of the nursing record,temperature sheet,first care record and medical order form of the experimental group after the medical records were revised were higher than the control group(P<0.05).In the experimental group,the incidence of missing items in the first nursing record,inconsistent condition with requirements,lack of continuity of records,failure to conduct specialized observations,failure to implement nursing measures,lack of medical records and lack of nursing feedback were all lower than the control group(P<0.05).In the experimental group,the nursing staff′s satisfaction scores for error avoidance,nursing electronic medical record quality control accuracy and quality control time-consuming were higher than the control group(P<0.05).Conclusion The application of medical record review and modification in nursing electronic medical record quality control has a significant effect,which can help to improve the quality of nursing medical record writing,prevent the occurrence of defects in nursing medical record writing,as well as promote the improvement of nursing staff satisfaction.

关 键 词：护理电子病历质控 病历阅改 护理病历 书写质量 书写缺陷 

分 类 号：R47[医药卫生—护理学]