摘要
目的针对护理记录书写存在的缺陷,进行规范管理,提高护理文书书写质量。方法采取PDCI持续质量改进法进行管理,即每季度评估分析400份护理记录,住院病历和出院病历各200份,全年共评估1600份护理病历,并将护理记录中存在的缺陷在医院信息网上进行反馈、点评、指导、改进,下季度针对上次的缺陷再进行评估、反馈、点评、指导、改进,如此周而复始。结果规范管理后护理记录书写质量明显提高。结论加强质控管理是保证护理记录书写质量的关键。
Objective Improving the nursing records quality via normalized management of the defects existing in preparing the nursing records. Methods Plan-Do-Check-Improve （PDCI） continuous quality improvement method was adopted to manage the quality of nursing records. 400 nursing records（200 records for in-patients and 200 records for discharged-patients） were evaluated each quarter, and the nursing records, also with the feedback, criticism and guidance on the defects, were simultaneously published on the hospital information network. And such kinds of defects should be brought up and evaluated again. Total 1 600 records were evaluated yearly. Results The quality of nursing records was significantly improved after adopting PDCI method. Conclusion Strengthening the quality control is the key factor to assure the quality of nursing records.
出处
《中华全科医学》
2010年第12期1636-1637,共2页
Chinese Journal of General Practice
关键词
护理记录
质量
改进
提高
Nursing records
Quality
Improvement
Enhancement
