摘要
目的为了提高危重病护理文书的书写质量,探讨实施病区质量控制的效果。方法对2018年1月1日-2018年12月31日和2019年1月1日-2019年12月31日入住呼吸监护室患者的护理文书进行书写质量检查,2018年为质量控制前组,2019年为质量控制后组,2018年按照某院的管理规定实施护理文书书写质量控制管理,2019年在2018年的基础上,加强病区护理文书书写质量控制管理,书写者对护理文书进行自查,病区的护理文书书写质量控制检查员对所有入住监护室的护理文书进行书写质量检查。比较两组的护理文书书写书写质量。结果质量控制前组文书数为49例,质量控制后组文书数为47例,质量控制前组护理文书书写问题的发生率为85.71%,质量控制后护理文书出现问题的发生率为25.53%,两组比较差异有统计学意义,P<0.01。质量控制后组记录缺乏客观性、重要症状描述不具体、重要内容漏记发生的次数均较质量控制前组有明显的降低,两组比较P<0.05,差异具有统计学意义。结论实施病区质量控制管理可以进一步有效地提高护理文书的书写质量,是提高护理文书书写质量一种有效手段。
Objective To improve the writing quality of critical care records,the effect of implementing secondary quality control in ward was discussed.Methods The writing quality of nursing documents of patients admitted to respiratory intensive care unit from January 1,2018 to December 31,2018 and from January 1,2019 to December 31,2019 were checked.2018 is the pre-quality control group and 2019 is the post-quality control group.The quality control management of nursing document writing was carried out in 2018 according to the management regulations of a hospital.In 2019,on the basis of 2018,the quality control management of nursing document writing in the ward was strengthened,and the writer carried out self-examination of the nursing document.The ward nursing document writing quality control inspector checked the writing quality of all nursing documents admitted to the intensive care unit.The writing quality of the two groups is compared.Results There were 49 cases before quality control and 47 cases after quality control.The incidence of problems in nursing records before quality control was 85.71%,and the incidence of problems in nursing records after quality control was 25.53%.The difference between the two groups was statistically significant,P<0.01.After quality control,the records lacked objectivity,the description of important symptoms was not specific,and the number of important content missing records was significantly reduced compared with that before quality control.P<0.05 was compared between the two groups,and the difference was statistically significant.Conclusion The implementation of secondary quality control management in ward can effectively improve the writing quality of nursing records and is an effective means to improve the writing quality of nursing records.
作者
王莹
崔更力
王文娟
Wang Ying;Cui Gengli;Wang Wenjuan(Respiratory Department,Beijing Jishuitan Hospital,Beijing 100035,China;不详)
出处
《中国病案》
2020年第6期11-13,共3页
Chinese Medical Record
关键词
危重病
护理文书
书写质量
病区
质量控制
Critical illness
Nursing documents
Writing quality
Ward
Quality control
