摘要
目的结合临床实践分析急诊病房护理中缺陷项目,明确护理观察要点,减少护理记录缺陷,提升护理质量。方法于2019年10月起将常规护理记录检查管理模式改为缺陷护理记录针对性管理模式。随机选取2018年9月1日-2019年9月30日98例患者护理记录作为常规组,选取2019年10月1日-2020年12月31日98例患者护理记录作为管理组,比较两组患者护理质量评分和病历质量评分及护理记录单缺陷。结果管理组患者护理质量评分和病历质量评分明显高于常规组;管理组护理记录缺陷发生率明显低于常规组;管理组护理记录书写质量缺陷发生率低于常规组,但差异无统计学意义。结论护理记录缺陷分析可以明确护理观察要点,锻炼护士思维能力,提高护理记录质量和患者满意度。
Objectives To analysis the defects of nursing in emergency ward,clarify the key point of nursing observation,reduce the defects of nursing records,and improve the quality of nursing.Methods From October 2019,the routine nursing record inspection management mode was changed to the defect nursing record targeted management mode.The nursing records of 98 patients from September 1st,2018 to September 30th,2019 were randomly selected as the routine group,and the nursing records of 98 patients from October 1st,2019 to December 31st,2020 were selected as the management group.The nursing quality score,medical record quality score and nursing record sheet defects of the two groups were compared.Results The nursing quality score and medical record quality score of patients in management group were significantly higher than those in routine group.The incidence of nursing record defects in the management group was significantly lower than that in the routine group.The incidence of nursing record writing quality defects in the management group was lower than that in the conventional group,but the difference was not statistically significant.Conclusions Defect nursing record analysis could clarify the key points of nursing observation,exercise nurses’thinking ability,improve the quality of nursing record and patients’satisfaction.
作者
丁虹
陈瑜
杨彬
Ding Hong;Chen Yu;Yang Bin(Department of Emergency,Ruijin Hospital(North),Shanghai Jiaotong University of Medicine,Shanghai 201805,China;不详)
出处
《中国病案》
2022年第10期12-14,共3页
Chinese Medical Record
关键词
护理记录
缺陷管理
急诊科
不良事件发生率
Nursing record
Defect management
The emergency department
Incidence of adverse events
