广西临床护理质量评价及检查标准

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1、广西临床护理质量评价及检查标准（试  行） 广西壮族自治区卫生厅二○○八年九月 策  划：尤剑鹏编写组：梁  远  王建政  张益民  应燕萍  胡艳宁  崔妙玲  雪丽霜              杨红叶  马丽娅  李新萍  张萍萍  戴艳萍  马  辉校  对：崔妙玲  马  辉 前   言质量不仅关系到医院的生存和效益，也直接影响患者的健康和安全。医疗护理工作直接为患者服务，更能反映出质量是生存的内涵。因此护理质量管理至关重要，是护理管理的根本任务。特别是近几年卫生部 “以病人为中心，以提高医疗服务质量为主题”的医院管理年活动的开展，对护理质量提出了更高的要

2、求。    护理质量是指护理工作为患者提供护理技术和生活服务效果的程度。它是衡量护理管理水平、护理业务技术水平和工作效果的重要标志。《广西临床护理质量评价及检查标准》是根据《医院管理评价标准实施细则》要求修订，坚持以质量管理为核心、技术管理为重点、组织管理为保证，通过对护理工作的监控，使护理人员在业务行为、思想职业道德等方面都符合客观的要求和患者需要，使护理工作能够以最短的时间、最好的技术、最低的成本，产生最优化的治疗护理效果，最终实现为患者提供优质服务的目的。本书是在充分采纳各级护理管理人员意见及总结近几年护理管理经验的基础上编制而成的。各级各类医疗机构必须遵照执

3、行，并在执行的过程中总结经验，对发现的问题及时反馈，以便进一步修订、完善。                            广西壮族自治区卫生厅                                 二〇〇八年十月二十八日 目   录 第一部分  护理质量评价指标及计算方法1. 护理质量评价指标及计算方法·············································· (1) 第二部分  护理质量检查表1. 三级质控护理质量改进记录表·············································

4、· (5)2. 二级质控护理质量改进记录表·············································· (6)3. 二级质控护理质量检查汇总表·············································· (7)4. 一级质控护理质量改进记录表4．1 一级质控护理质量改进记录表（特殊区域）····················· (8)4．2 一级质控护理质量改进记录表（供应室）························· (9)4．3 一级质控护理质量改进记录表（门诊）·············

5、············· (10)4．4 一级质控护理质量改进记录表（病房）··························· (11) 第三部分  各项护理质量考核评分标准1. 普通病区管理质量考核评分标准········································· (12)2. 分级护理质量考核评分标准················································ (16)2．1  特级护理质量考核评分标准·········································· (16)2

6、．2  一级护理质量考核评分标准·········································· (19)2．3  二级护理质量考核评分标准·········································· (22)2．4  三级护理质量考核评分标准·········································· (25)3. 急救物品管理质量考核评分标准········································ (28)4. 护理文书书写质量考核评分标准················

7、························ (30)5. 消毒隔离质量考核评分标准··············································· (33)6. 消毒供应室工作质量考核评分标准····································· (36)7. 手术室工作质量考核评分标准············································ (40)8.ICU工作质量考核评分标准················································