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1、护理记录质量持续改进的分析与控制黄继菊(四川省广汉市人民医院外二科四川广汉618300)【摘要】目的加强护理书写质量分析与控制,提高书写质量,减少法律隐患。方法随机抽查2012下半年和2013年上半年的全院各科在架病历各280份的护理书写质量进行对比,2012年下半年为对照组,2013年上半年为观察组,在此基础上,护理部2013年质量规划加强了护理书写的质量监管力度及改进了质控方法。结果将两组护理书写质量分别进行比较,观察组在医学术语的规范性、记录的连贯性、疾病的专科特色、健康教育的完善、安全防范措施的落实等方面,明显优于对照组,合格
2、率提高了1.2%,护理书写质量明显提高。结论通过对护理记录进行检查、分析,持续改进其中缺陷,提高了书写质量,同时提升了护士职业素质【关键词】护理记录持续改进分析与控制【中图分类号】R471【文献标识码】A【文章编号】2095-1752(2013)29-0109-02AnanalysisandcontrolofhowtoconstantlyimprovethequalityofthenursingrecordhandwritingHuangJiju{SurgerySection2,SichuanGuanghanPeople’
3、sHospitalGuanghan,Sichuanprovince618300}[Abstract]Aims:Tostrengthentheanalysisandcontrolofthequalityofthenursingrecordhandwriting,toimprovethequalityofthenursingrecordhandwriting,andhencetoreducethedisputesbetweenthehospitalandthepatientsApproaches:Outofthethesecondhalf
4、of2012andthefirsthalfof2013on-shelfmedicalrecordsofthewholehospital,randomlyspotcheck280copiesseparatelyandmakeacomparisonbetweenthem,theformeryearrecordsbeingcomparedgroup,andthelatterbeingobservedgroup.Furthermore,thenursingdepartment,inthequalitymanagementplanningfor
5、2013,strengthenedtheanalysisandcontrolofthequalityofthenursingrecordinghandwritingandimprovedthequalityofthenursingrecordinghandwriting.Results:Afterindividuallycomparingthequalitybetweenthetwogroups’nursingrecordinghandwriting,theobservedgrouparefoundtobeobviousl
6、ybetterthanthecomparedgroup,intheaspectssuchasthespecificationsofmedicalterms,continuityofrecords,specialistfeaturesofdiseases,theperfectionofhealtheducationandtheimplementationofsafetyprecautions,withthepassrateupby1.2%andthequalityofrecordinghandwritingsignificantlyim
7、proved.Conclusion:Bychecking,analyzingthenursingrecordhandwriting,andconstantlycorrectingthedefects,wehaveimprovedthenursingrecordhandwritingandenhancedthenurses’professionalquality.【Keywords】NursingrecordhandwritingConstantlyimproveAnalysisandcontrol自2010年3月卫生部新的
8、《病历书写基本规范》及2010年7月《侵权责任法》等相关文件出台,护理记录作为住院病人医疗文件记录中的一个重要组成部分,更加成为重要的法律文书,患者有权复印、复制。它反映了护士观察、治疗、护理病人的全过程,对确保病人安全