摘要
目的探讨护理文书书写中断管理模型的设置及应用效果。方法基于探索图初步构建护理文书书写中断管理模型,经过2轮德尔菲专家函询进行修订,应用于移植外科病房的护理文书书写质控。结果实施后发生护理中断事件528例次,其中护理文书书写中断发生35例次;实施前分别为691例次、81例次,实施前后比较,差异有统计学意义(P<0.01);实施后护理文书书写缺陷发生情况显著减少,科室护理文书书写质量在全院40个病区护理单元中排名第一。结论中断管理模型的应用有利于降低护理文书书写中断的发生,可提升护理文书书写质量。
Objective To explore a nursing documentation interruption management model and to observe the effect of its application.Methods Researchers constructed an initial version of nursing documentation interruption management model based on the probe graph,then the model was subjected to two rounds of expert consultation through the Delphi technique.The model was applied in quality control of nursing documentation in a transplant surgery unit.Results After application of the interruption management model,there were 528 nursing interruptions service,among which there were 35 interruptions during nursing documentation,versus 691 and 81 interruptions respectively before,with the incidence rates of total interruptions and interruptions during nursing documentation significantly being less than before（P〈0.01）.The counts of flaws in nursing records were reduced obviously after implementation,and the quality of nursing records in the transplant surgery unit was ranked in the first place among 40 nursing units.ConclusionImplementation of the interruption management model can effectively minimize interruptions during nursing documentation,and promote the quality of nursing records.
作者
谢建飞
刘佳
刘立芳
王璐
王琰
吴小霞
丁四清
周建大
郑树基
Xie Jianfei;Liu Jia;Liu Lifang;Wang lu;Wang Yan;Wu Xiaoxia;Ding Siqing;Zhou Jianda;Zheng Shuji(Transplant Center,3rd Xiangya Hospital,central South University,Changsha 410013,China)
出处
《护理学杂志》
CSCD
北大核心
2018年第18期4-7,共4页
Journal of Nursing Science
基金
湖南省自然科学基金项目(2018JJ3779)
中南大学湘雅三医院"新湘雅人才工程精医助跑计划"资助项目(JY201720)
关键词
护理文书
文书书写
中断管理模型
护理中断
书写缺陷
质量管理
nursing records
documentation
interruption management model
nursing interruptions
records flaws
quality management
