对烧伤整形科护士实施护理病历质控管理方法的分析  

Analysis on the Quality Control Management Method of Nursing Medical Records Implemented by Nurses in Burn and Plastic Surgery Department

作　　者：范钟元 何靓男 张雪娟 FAN Zhongyuan;HE Liangnan;ZHANG Xuejuan(Department of Burns and Plastic Surgery,Mianyang Hospital Affiliated to University of Electronic Science and Technology of China(Mianyang Central Hospital)Mianyang,Sichuan Province,621000 China)

机构地区：[1]电子科技大学医学院附属绵阳医院(绵阳市中心医院)烧伤整形外科,四川绵阳621000

出　　处：《中国卫生产业》2023年第13期35-38,共4页China Health Industry

摘　　要：目的探究为烧伤科整形护士实施护理病历质控管理方法的效果。方法选取2021年9月—2022年8月期间电子科技大学医学院附属绵阳医院烧伤科护士21名作为研究对象,将烧伤科整形出院病历随机均分为两组。参照组开展常规护理病历管理方法,研究组开展护理病历质控管理方法,对2组质控效果、护士管理评分与护士对病历管理措施的满意度进行对比分析。结果经管理后,研究组病历的质控时间短于参照组病历,病历质控失误次数显著低于参照组病历,研究组病历记录单、护理记录单、体温单以及医嘱单评分均显著高于参照组病历,差异有统计学意义(P<0.05)。且经管理后,研究组护士对于病历管理措施的满意度高于参照组护士,差异有统计学意义(P<0.05)。结论为烧伤科整形护士实施护理病历质控管理方法,能够显著提升病历质控效果及病理评分,同时护士对于该管理方法的满意度更高。Objective To explore the effect of implementing nursing medical record quality control management method for plastic nurses in burn department.Methods A total of 21 nurses from the Department of Burns and Plastic Surgery from September 2021 to August 2022 in Mianyang Hospital Affiliated to University of Electronic Science and Technology of China and Mianyang Central Hospital were selected as the research objects.The medical records of plastic surgery discharged from the Department of Burns were randomly divided into 2 groups.The reference group carried out routine nursing medical record management methods,and the study group carried out nursing medical record quality control management methods.The quality control effect,nurse management score and nurses'satisfaction with medical record management measures in the two groups were compared and analyzed.Results After management,the quality control time of the medical records of the study group was shorter than that of the reference group,and the number of quality control errors of the medical records was significantly lower than that of the reference group.The scores of the medical records,nursing records,temperature sheets,and doctor's orders of the study group were significantly higher than those of the reference group,and the difference was statistically significant(P<0.05).And after the management,the satisfaction of the nurses in the study group with the medical record management measures was higher than that of the nurses in the reference group,and the difference was statistically significant(P<0.05).Conclusion Implementing nursing medical record quality control management method for plastic nurses in burn department can significantly improve the quality control effect of medical record and pathological score,and nurses are more satisfied with this management method.

关 键 词：烧伤整形科 护理病历 质量控制 护理管理 

分 类 号：R473[医药卫生—护理学]