国际护理学杂志
國際護理學雜誌
국제호이학잡지
INTERNATIONAL JOURNAL OF NURSING
2011年
7期
1036-1038,1073
,共4页
自行设计%病历质控检查表%护理病历%持续质量改进
自行設計%病歷質控檢查錶%護理病歷%持續質量改進
자행설계%병력질공검사표%호리병력%지속질량개진
Self-designed%Records quality control check list%Nursing records%Quality improvement continuously
目的 落实医疗制度,保障医疗安全,防范医疗风险,分析护理病历中存在的主要缺陷,探讨一种提高病区护理病历质量的有效方法.方法 自行设计病历质控检查表应用于临床工作中,抽查我院已提交部分病历4 180份,将传统方法的对照组病历(2009年前)和观察组病历(2009年后)进行对照分析.结果 根据病历书写基本要求,观察组缺陷病历明显少于对照组病历,差异有统计学意义(P<0.01).结论 病历质控检查表可把病历缺陷消灭在病历的形成过程中,达到病案质量监控效果的最大化,是全面质量管理在病历管理中的具体应用,是对护理病历质量实行持续改进的有效方法.
目的 落實醫療製度,保障醫療安全,防範醫療風險,分析護理病歷中存在的主要缺陷,探討一種提高病區護理病歷質量的有效方法.方法 自行設計病歷質控檢查錶應用于臨床工作中,抽查我院已提交部分病歷4 180份,將傳統方法的對照組病歷(2009年前)和觀察組病歷(2009年後)進行對照分析.結果 根據病歷書寫基本要求,觀察組缺陷病歷明顯少于對照組病歷,差異有統計學意義(P<0.01).結論 病歷質控檢查錶可把病歷缺陷消滅在病歷的形成過程中,達到病案質量鑑控效果的最大化,是全麵質量管理在病歷管理中的具體應用,是對護理病歷質量實行持續改進的有效方法.
목적 락실의료제도,보장의료안전,방범의료풍험,분석호리병력중존재적주요결함,탐토일충제고병구호리병력질량적유효방법.방법 자행설계병력질공검사표응용우림상공작중,추사아원이제교부분병력4 180빈,장전통방법적대조조병력(2009년전)화관찰조병력(2009년후)진행대조분석.결과 근거병역서사기본요구,관찰조결함병력명현소우대조조병력,차이유통계학의의(P<0.01).결론 병력질공검사표가파병력결함소멸재병력적형성과정중,체도병안질량감공효과적최대화,시전면질량관리재병력관리중적구체응용,시대호리병력질량실행지속개진적유효방법.
Objective To analyze the main defects in the nursing records, explore an effective method to improve the quality of nursing records.Methods A total of 4 180 records copies were selected. Before 2009 of those as control group were examined with routine method, while after 2009 of those as observation group were examined with self-designed records quality control check list. The results were compared.Results According to the nursing records writing basic requirements , the difference was statistically significant(P<0.01) ,and defects in observation group were obviously less than those in control group.Conclusions Using this list can eliminate defects in forming the nursing records process. It is an effective method of improving continuously the quality of nursing records.
