品管圈下的信息化管理对策在电子手术护理记录单中的应用  

Application of Information Management Strategies within a Quality Control Circle in Electronic Surgical Nursing Records

作　　者：刘伟[1] 向承红[1] 耿苗苗[1] 徐艳杰 王晨[2] Liu Wei;Xiang Chenghong;Geng Miaomiao;Xu Yanjie;Wang Chen(Operating Room,Beijing Chaoyang Hospital(Shijingshan Campus),Capital Medical University,Beijing 100043,China;不详)

机构地区：[1]首都医科大学附属北京朝阳医院(石景山院区)手术室,北京市100043 [2]首都医科大学附属北京朝阳医院门诊办公室,北京市100020

出　　处：《中国病案》2024年第7期12-14,共3页Chinese Medical Record

摘　　要：目的应用品管圈活动实施干预对策的方法,以达到提升电子手术护理记录单书写质量的目的。方法成立品管圈小组,以降低电子手术护理记录单书写缺陷发生率为主题,选取品管圈实施前2022年11月1日-2023年4月30日的856份电子手术护理记录单为对照组,品管圈实施后的2023年6月1日-2023年11月30日,同一组护理人员书写的862份电子手术护理记录单作为观察组,进行书写质量现状调查,将存在书写缺陷的记录单数据进行统计学分析,确认改进目标,通过品管圈手法制定对策进行干预,比较干预前后手术护理记录单书写缺陷发生率以及圈员的能力。结果观察组电子手术护理记录单书写缺陷发生率为5.1%低于品管圈活动前的13.2%,差异具有统计学意义P<0.05,品管圈活动目标达成率为104.55%,进步率为61.48%。圈员素质能力均正向成长。结论品管圈活动的实施降低了电子手术护理记录单书缺陷发生率,提高了护理人员的素质和能力。Objectives This study aims to apply quality control circle activities to implement intervention countermeasures in order to improve the writing quality of electronic surgical nursing records.Methods A quality control circle group with the theme of reducing the incidence of writing defects in electronic surgical care records was established.856 electronic surgical nursing records from November 1,2022 to April 30,2023 before the implementation of the quality control circle,were selected as the control group.From June 1,2023 to November 30,2023 after the implementation of the quality control circle,862 electronic surgical nursing records written by the same group of nursing staff served as the observation group.A survey on the current status of writing quality was conducted.Statistical analysis on record sheet data with writing defects was conducted to confirm improvement goals.Countermeasures and intervention were developed through quality control circle techniques.The incidence of writing defects in surgical care records and the ability of circlers before and after intervention was compared.Results The incidence rate of writing defects in electronic surgical nursing records in the observation group was 5.1%,which was lower than 13.2%before the quality control circle activity.The difference was statistically significant(P<0.05).The achievement rate of quality control circle activity goals was 104.55%,and the progress rate was 61.48%.All circle members'quality abilities showed positive growth.Conclusions The implementation of the quality control circle has reduced the rate of defects in nursing records and the rate of reworking medical records and improved the quality and ability of nursing staff.

关 键 词：品管圈 手术护理记录单 电子病历 缺陷率 信息化 

分 类 号：R472.3[医药卫生—护理学]