摘要
目的探究与分析环节管理对终末护理病历质量的影响。方法选取我院自2019年12月—2020年12月收集的来源于各科室的终末护理病历1 080份资料进行研究,按照不同的管理方法分为常规管理组与环节管理组,各540份,对比两组终末护理病历在不同管理下存在缺陷的情况、质量评分及患者对终末护理病历质量的满意度。结果环节管理组与常规管理组相比病历书写缺陷、体温单书写缺陷、医嘱单书写缺陷、入院护理评估单书写缺陷、护理记录书写缺陷发生率均较低,差异具有统计学意义(P <0.05)。环节管理组与常规管理组相比体温单、医嘱单、首次护理记录单及护理记录单质量评分均较高,差异具有统计学意义(P <0.05)。环节管理组与常规管理组相比患者对终末护理病历质量的满意度均较高,差异具有统计学意义(P <0.05)。结论环节管理在终末护理病历质量中的应用可减少缺陷情况的出现,终末护理病历质量得以提升,患者对终末护理病历质量的满意度也较高。
Objective To explore and analyze the impact of link management on the quality of end-of-life care medical records. Methods We selected 1 080 end-of-life care medical records collected from each department from December 2019 to December 2020 in our hospital for research. According to different management methods, they were divided into routine management group and link management group, each with 540 copies, compare the defects of the two groups of terminal care medical records under different management, quality scores and patients’ satisfaction with the quality of terminal care medical records. Results Compared with the routine management group, the incidence of medical record writing defects, temperature sheet writing defects, doctor order writing defects, admission nursing evaluation sheet writing defects, and nursing record writing defects were lower in the link management group, and the difference was statistically significant(P < 0.05). Compared with the routine management group, the quality scores of temperature sheet, doctor’s order sheet, first care record sheet and nursing record sheet were higher in the link management group, and the difference was statistically significant(P < 0.05). Compared with the routine management group, patients in the link management group were more satisfied with the quality of end-of-life care medical records, and the difference was statistically significant(P < 0.05). Conclusion The application of link management in the quality of terminal care medical records can reduce the appearance of defects, the quality of terminal care medical records can be improved, and patients are more satisfied with the quality of terminal care medical records.
作者
刘春华
LIU Chunhua(Medical Record Quality Control Room,Liaocheng Traditional Chinese Medicine Hospital,Liaocheng Shandong 252000,China)
出处
《中国卫生标准管理》
2021年第14期26-28,共3页
China Health Standard Management
关键词
环节管理
终末护理病历
质量
缺陷
护理记录单
满意度
link management
terminal care medical record
quality
defect
nursing record sheet
satisfaction
