全员参与护理文书管理在重症监护室低年资护士中的应用  

Application of Full Participation in Nursing Document Management in Junior Nurses in Intensive Care

作　　者：谭学增 王芹 谢丹婷 胡江滨[1] 范凤云[1] 何园园 UnitTan Xuezeng;Wang Qin;Xie Danting;Hu Jiangbin;Fan Fengyun;He Yuanyuan(Hainan Hospital of PLA General Hospital,Sanya 572013,Hainan Province,China;不详)

机构地区：[1]解放军总医院海南医院,海南省三亚市572013

出　　处：《中国病案》2023年第9期27-29,共3页Chinese Medical Record

基　　金：三亚市哲学社会科学项目(SYSK2020-15)。

摘　　要：目的探讨全员参与护理文书管理在重症监护室低年资护士中的应用效果,提高护理文书质量与满意度。方法采用历史性对照研究方法,选择2019年10月1日-2020年9月30日500份重症护理文书为对照组,实施常规文书质控模式,2020年10月1日-2021年9月30日500份重症护理文书为观察组,实施全员参与护理文书管理模式,比较2组护理文书质控问题数及护士满意度。结果观察组问题检出数合计为6054条,对照组合计为3468条。对照组二级质控检出问题数2675条,三级质控检出问题数793条,全员参与护理文书管理组一级质控检出问题数3708条,二级质控检出问题数1848条,三级质控检出问题数498条,全员参与护理文书管理组二级、三级质控检出问题数明显少于对照组,且护士满意度明显高于对照组。结论全员参与护理文书管理能有效提升低年资护士护理文书质量,且有效提高护士满意度。Objectives This study aims to explore the effect of full participation in nursing document management in junior nurses in intensive care units.Methods Historical control study method was adopted.500 ICU nursing documents from October 1,2019 to September 30,2020 were selected as the control group,and the routine document quality control mode was implemented.500 ICU nursing documents from October 1,2020 to September 30,2021 were selected as the observation group.Full participation in nursing document management was implemented.The number of nursing document quality control problems and nurses’satisfaction were compared between the two groups.Results In the observation group,6054 quality control problems were detected,and 3468 problems were detected in the coutrol group.In the control group,there were 2675 problems detected by level-2 quality control,and 793 problems detected by level-3 quality control.3708 problems were detected by level-1 quality control,1848 problems were detected by level-2 quality control,and 498 problems were detected by level-3 quality control in the full participation nursing document management group.The number of problems detected by level-2 and level-3 quality control in the full-participation nursing document management group was significantly less than that in the control group and the satisfaction of nurses was significantly higher than that in the control group.Conclusions Full participation in the management of nursing documents can effectively improve the quality of nursing documents of junior nurses and effectively improve the satisfaction of nurses.

关 键 词：护理文书 重症监护 满意度 护士 

分 类 号：R47[医药卫生—护理学]