摘要
目的分析PDCA循环联合头脑风暴法在护理文书质控中的应用效果。方法选取2023年1月1日—12月31日泰安市妇幼保健院出院的病案1454份为研究对象,2023年7月1日起实施PDCA循环联合头脑风暴法,将实施前(2023年1月1日—6月30日)的病案727份作为对照组,实施常规护理文书质量管理;实施后(2023年7月1日—12月31日)的727份病案作为研究组,实施PDCA循环联合头脑风暴法对护理文书质量进行质控管理。比较2组护理文书书写的合格情况、质量评分及书写问题情况。结果研究组护理文书书写优秀、合格、不合格、总合格分别为566份(77.85%)、146份(20.08%)、15份(2.06%)、712份(97.94%),对照组护理文书书写优秀、合格、不合格、总合格分别为395份(54.33%)、254份(34.94%)、78份(10.73%)、649份(89.27%)。研究组护理文书书写总合格率高于对照组,护理文书书写质量优于对照组,差异均有统计学意义(P<0.05)。研究组的医嘱单、体温单、一般护理记录单、手术护理记录单、危重患者护理记录单及护理文书书写质量总分分别为(9.27±0.56)分、(18.84±0.90)分、(28.64±0.72)分、(9.02±0.37)分、(28.36±0.69)分、(94.13±2.47)分,高于对照组的(8.99±0.33)分、(18.60±0.71)分、(28.31±0.71)分、(8.95±0.32)分、(26.18±0.91)分、(91.03±2.33)分,差异均有统计学意义(P<0.05)。研究组未使用医学术语、未记录、未签名或代签名、医护记录不一致的发生率(5.64%、3.30%、2.20%、2.20%)低于对照组(25.86%、31.50%、21.32%、31.50%),差异均有统计学意义(P<0.05)。结论PDCA循环联合头脑风暴法应用于护理文书质控,可提高护理文书书写的合格率和质量,降低护理文书书写问题的发生率。
Objective To analyze the application effect of PDCA cycle combined with brainstorming method in the quality control of nursing documents.Methods A total of 1454 medical records discharged from Tai'an City Maternity and Child Health Hospital from January 1,to December 31,2023 were selected as the research subjects.Starting from July 1,2023,the PDCA cycle combined with brainstorming method was implemented.A total of 727 medical records before implementation(January 1,to June 30,2023)were used as the control group,and routine nursing document quality management was implemented;a total of 727 medical records after implementation(from July 1,to December 31,2023)were selected as the research group to implement the PDCA cycle combined with brainstorming method for quality control management of nursing documents.The qualification,quality rating,and writing issues of two groups of nursing documents were compared.Results The research group had 566 cases(77.85%)of excellent nursing writing,146 cases(20.08%)of qualified,15 cases(2.06%)of unqualified,and 712 cases(97.94%)of overall qualified nursing writing.The control group had 395 cases(54.33%)of excellent nursing writing,254 cases(34.94%)of qualified,78 cases(10.73%)of unqualified,and 649 cases(89.27%)of overall qualified nursing writing.The overall pass rate of nursing document writing in the research group was higher than that in the control group,and the quality of nursing document writing was better than that in the control group,with statistically significant differences(P<0.05).The total scores of the quality of medical orders,temperature records,general nursing records,surgical nursing records,critical patient nursing records,and the total score of nursing document writing quality in the research group were(9.27±0.56)points,(18.84±0.90)points,(28.64±0.72)points,(9.02±0.37)points,(28.36±0.69)points,and(94.13±2.47)points,respectively,which were higher than those of the control group,which were(8.99±0.33)points,(18.60±0.71)points,(28.31±0.71)points,(8.95±0.32)points,(26.18±0.91)points,and(91.03±2.33)points,and the differences were statistically significant(P<0.05).The incidence of not using medical terminology,no record,not signed or signed on behalf,inconsistent medical records in the research group(5.64%,3.30%,2.20%,2.20%)was higher than that in the control group(25.86%,31.50%,21.32%,31.50%),and the difference was statistically significant(P<0.05).Conclusion The application of PDCA cycle combined with brainstorming method in nursing document quality control can improve the qualification rate and quality of nursing document writing,and reduce the incidence of nursing document writing problems.
作者
陈现玲
陈晓
CHEN Xianling;CHEN Xiao(Quality Control Division,Tai'an City Maternity and Child Health Hospital,Tai'an Shandong 271000,China;Department of Emergency,Tai'an City Central Hospital,Tai'an Shandong 271000,China)
出处
《中国卫生标准管理》
2025年第14期12-15,共4页
China Health Standard Management
关键词
PDCA循环
头脑风暴法
护理文书
质量控制
病历书写规范
应用效果
PDCA cycle
brainstorming method
nursing document
quality control
standardization of medical record writing
application effect
