摘要
目的：通过前瞻性管理模式的实施,对急诊科护理文书质量目前存在或反复存在的共性问题进行回顾性分析,提出有效的整改措施,督促急诊科护理文书质量持续改进。方法：随机抽取急诊科2009年2月~2010年2月入院患者的护理记录资料180份进行全程调研和督查,针对所存在的护理文书质量问题进行评价、检查、探讨,对严重问题进行督促和整改,由原记录者重抄。结果：前瞻性管理模式在控制急诊科护理文书质量中确实可行,质量监督控制措施行之有效,护理文书客观、真实、准确、完整,客观反映患者接受治疗和护理的全过程。结论：护理文书质量管理的目的是纠正护理记录的偏差,使护理文书更具科学性、真实性、准确性和完整性,客观地反映了护理的全过程,对护理文书的管理具有积极的督导和促进作用。
Objective：To go through the implementation of the forward-looking management, the common problems of currently exist or repeated exist of the quality of the emergency department care to be retrospective analyzed, and to be propose effective corrective measures, to be urge the department of emergency nursing quality counld be improving. Methods： 180 cases of the hospital patient care records was investigated and inspected fully, which were extracted randomly from emergency department from February 2009 to February 2010. The existing problem about the quality of care instrument was evaluated, examined and discussed; the serious problem was supervised and corrected, and the records were rewritten by the original amanuensis. Results：Forward-looking management in controlling the quality of emergency department care instrument was feasible assuredly, quality supervision and control measures were effective. The care instrument was objective, true, exact and complete, and it reflected the whole process of the patient to receive treatment and care objectively. Conclusion：The quality of care instrument management aims at correcting nursing records of the deviation, makes the care instrument be more scientific, real, exact and complete, reflects the whole process of nursing, and it has supervision and promoting positive role.
出处
《中国当代医药》
2010年第21期137-138,共2页
China Modern Medicine
关键词
前瞻性管理模式
急诊科
护理文书质量
Forward-looking management
Emergency department
The quality of care instrument
