摘要
目的探讨护理文件书写质量现状及其干预对策。方法选择2011年1月～2012年1月温州市平阳县中医院永新分院150份病历作为对照组,选择同期总院的150份病历作为研究组,对照组采用传统的护理文件书写终末质量检查方法,观察组采用改进的护理文件书写文件书写质量与终末质量同时监控的方法,比较两组护理文件书写质量评分、患者满意度、不良事件发生率、体温单、医嘱单、护理记录单检查结果。结果①对照组文件书写质量评分、患者满意度及不良事件发生率与研究组相比,差异具有统计学意义(P<0.05,P<0.01);②体温单方面:两组版面涂改、项目填写、未按规定测定生命体征以及记录不准确等方面具有统计学意义(P<0.05,P<0.01);③医嘱单方面:两组版面涂改、项目填写、未按规定测定生命体征以及记录不准确等方面具有统计学意义(P<0.05,P<0.01);④护理记录单方面:两组在版面涂改、记录不够及时、医护描述情况不相符、未使用医学术语、病情动态变化未体现以及执行时医嘱与护理记录时间不一致等方面的差异均具有统计学意义(P<0.05,P<0.01)。结论将改进的护理文件书写方法应用于护理文件书写质量控制之中,能够明显提高护理质量及患者满意度,值得加以推广并应用。
Objective To investigate the quality of nursing documentation writing status and solutions. Methods Se- lected 150 medical records in the hospital of Wenzhou Pingyang Yongxin Branch from January 2011 to January 2012 as the control group, and to select 150 medical records of the General Hospital over the same period as the study group. And the control group was given the traditional nursing documentation writing terminally quality checking method, and the observation group was given the improved writing quality of nursing documentation writing files with the terminal. The quality of writing quality score of nursing documentation, patients＇ satisfaction, incidence of adverse events, body temperature single prescription orders, nursing records check a result of the two groups of patients were compared. Results ①There was a statistical difference of the file writing quality scores, patients＇ satisfaction and the incidence of adverse events between the two groups （P 〈 0.05, P 〈 0.01 ）. ②Temperature unilateral： Two layout altered, the project completed, according to the specified measurement inaccurate recording of vital signs and other aspects of a significant difference （P 〈 0.05, P 〈 0.01 ）; ③ Exparte orders： two layout altered, the project completed, according to the specified measurement inaccurate recording of vital signs and other aspects of a significant difference （P 〈 0.05, P 〈 0.01 ）; ④Care record unilateral： both groups in the layout altered, recording was not enough time, health care does not match the description of the situation, the medical term is not used, the condition did not reflect the dynamic changes, and perform recording time when orders are inconsistent with nursing and other differences were statistically signifi cant （P 〈 0.05, P 〈 0,01 ）. Conclusion The improved nursing documentation method of writing is used in nursing doc- umentation writing quality control, can significantly improve the quality of care, patient satisfaction, and it is worthy of promotion and application.
出处
《中国现代医生》
2013年第33期144-146,共3页
China Modern Doctor
基金
浙江省平阳县社会发展科技计划项目(Y2012A09)
关键词
护理文件书写
质量控制
干预对策
Nursing documentation writing
Quality control
Intervention measures
