PDCA在儿科护理文书书写质量管理的应用  

Application of PDCA Model in Quality Management of Pediatric Nursing Document Writing

作　　者：王彦华 房萍[1] 周丽丽[1] Wang Yanhua;Fang Ping;Zhou Lili(Children’s Hospital Capital Institute of Pediatrics)

机构地区：[1]首都儿科研究所附属儿童医院,北京市100020

出　　处：《中国病案》2022年第8期8-10,共3页Chinese Medical Record

摘　　要：目的 采用PDCA模式对儿科护理文书书写进行质量管理,提高护理文书书写质量,保障医疗安全。方法 随机抽取2018年1月1日-2018年12月31日某院小儿内分泌科60例患儿的护理文书作为对照组,对其书写质量进行质量监控,开展PDCA循环管理,随机抽取实施改进措施后的2019年1月1日-2019年12月31日60例患儿的护理文书作为观察组。比较2组护理文书书写质量,并进行评价。结果 观察组护理文书质量评分(97.62±3.93)分高于对照组护理的(92.59±3.74)分,两组比较差异具有统计学意义,P<0.05。观察组各种风险评估不合格(6.67%)、护理记录缺项、漏项、记录不完整(3.33%)、护理记录复制(3.33%)、病情动态评估与描述不准确(5.00%)、与医师记录不一致(3.33%)及未体现专科特色(3.33%)的发生率与对照组(40.00%、15.00%、16.67%、20.00%、16.67%、36.67%)比较显著减少,差异具有统计学意义(P<0.05),合格率(96.67%)与对照组(90.00%)比较显著升高,差异具有统计学意义,(P<0.05)。结论 PDCA模式在护理文书书写质量管理中,能够降低护理文书书写错误率,提高某院内分泌科护理文书书写质量及合格率。Objectives To apply PDCA model to manage the quality of writing pediatric nursing documents,improve the quality of writing nursing documents, and ensure medical safety. Methods Nursing documents of 60children in pediatric endocrinology department of a hospital from January 1st, 2018 to December 31st, 2018 were randomly selected as the control group, and their writing quality was monitored. PDCA cycle management was carried out, and nursing documents of 60 children from January 1st, 2019 to December 31st, 2019 after the implementation of improved measures were randomly selected as the observation group. The writing quality of nursing documents in the two groups was compared and evaluated. Results The nursing document quality score of the observation group(97.62±3.93) was statistically significant compared with that of the control group(92.59±3.74)(P <0.05). The defect of nursing document in the observation group was significantly decreased compared with the control group(P<0.05), and the qualified rate of nursing document(96.67%) was significantly increased compared with the control group(90.00%)(P<0.05). Conclusions PDCA model in the quality management of nursing document writing could reduce the error of nursing document writing, improve the quality and pass rate of nursing document writing in endocrinology department of our hospital.

关 键 词：PDCA模式 儿科护理文书 书写质量 

分 类 号：R473.72[医药卫生—护理学]