质控小组干预下肿瘤科护理病历书写质量的效果观察  

The Effect of Quality of Oncology Nursing Chart Writing Under the Intervention of Quality Control Team

作　　者：岳雯 罗京 YUE Wen;LUO Jing(Jinshazhou Hospital,Guangzhou University of Traditional Chinese Medicine,Guangzhou 510168,China)

机构地区：[1]广州中医药大学金沙洲医院,广州510168

出　　处：《中国医药指南》2024年第4期156-158,共3页Guide of China Medicine

摘　　要：目的 观察质控小组干预下肿瘤科护理病历书写质量的效果。方法 选取广州中医药大学金沙洲医院肿瘤科2022年6月至2023年6月在院病历796份,按照质控干预前后时间,2022年6月—12月(407份病历)为传统组,2023年1月—6月(389份病历)为质控组。对两组的护理文书书写质量(规范性、完整性、准确性),以及护理文书书写各指标缺陷率进行比较。结果 质控组护理文书书写质量的规范性、完整、准确性评分均高于传统组,护理文书体温单频次错误、表单漏评错评、漏签名、记录不一致、项目漏填错填及书写错误缺陷比例均低于传统组(均P<0.001)。结论 肿瘤科通过建立护理文书质控小组,对护理病历进行交叉错查、系统质控,能提高护理病历书写质量,使护士更好、更快地掌握护理文书的规范性、完整性、准确性书写要求。Objective To observe the effect of the quality of nursing medical record writing in the Department of Oncology under the intervention of quality control group.Methods A total of 796 medical records in the oncology department of Jinshazhou Hospital of Guangzhou University of Traditional Chinese Medicine from June 2022 to June 2023 were selected,and according to the time before and after the quality control intervention,June-December 2022(407 medical records)was the traditional group and January-June 2023(389 medical records)was the quality control group.The quality of nursing instrument writing(standardization,completeness,and accuracy),as well as the rate of defects in each indicator of nursing instrument writing were compared between the two groups.Results The normality,completeness and accuracy scores of the quality of nursing instrument writing in the quality control group were higher than those of the traditional group,and the percentages of defects in the nursing instrument temperature sheet frequency error,form omission and wrong assessment,omission of signatures,inconsistent records,omission and wrong filling of items,and writing error defects were lower than those of the traditional group(all P<0.001).Conclusions Oncology department can improve the quality of nursing medical record writing and make nurses better and faster to master the standardization,completeness and accuracy writing requirements of nursing documents by establishing a nursing document quality control group to cross-check the errors and systematic quality control of nursing medical records.

关 键 词：质控小组 肿瘤科 护理病历 书写质量 

分 类 号：R73[医药卫生—肿瘤] R473.73[医药卫生—临床医学]