CAJ | 학술논문

　　目的：降低住院患者护理文书中日常病情记录缺陷率，保证记录的客观和完整性，避免医疗纠纷。方法：运用六西格玛管理方法，通过定义、测量、分析、改进、控制等5个步骤，对护理日常病情记录的质量现状进行调查、分析，找出影响护理日常病情记录质量的关键原因，提出整改措施。结果：书写护士的年资、书写的班次时间、质控方法、质控人员层级是影响护理日常病情记录质量的关键原因。经过改进，缺陷率从51%降至24.8%，Z值从1.475升至2.181，改进前后（P<0.05）有显著性差异。结论：应用六西格玛管理方法降低了住院患者护理文书中日常病情记录缺陷率。
　　목적：강저주원환자호리문서중일상병정기록결함솔，보증기록적객관화완정성，피면의료규분。방법：운용륙서격마관리방법，통과정의、측량、분석、개진、공제등5개보취，대호리일상병정기록적질량현상진행조사、분석，조출영향호리일상병정기록질량적관건원인，제출정개조시。결과：서사호사적년자、서사적반차시간、질공방법、질공인원층급시영향호리일상병정기록질량적관건원인。경과개진，결함솔종51%강지24.8%，Z치종1.475승지2.181，개진전후（P<0.05）유현저성차이。결론：응용륙서격마관리방법강저료주원환자호리문서중일상병정기록결함솔。
Objectives: To reduce the defects of nursing records for in-patients in routine care and assure the objectivity and integrity to avoid medical disputes. Methods: By Six Sigma method, the quality of nursing record is investigated and analyzed through "define-Measure-Analyze-Improve-Control" improvement pattern to find out key reasons influencing nursing record quality and propose countermeasures. Results: The seniority, writing times, the method of quality control and the level of quality control technician are the key to quality of nursing records. The defect rate is decreased from 51% to 24.8%(P<0.05) and Z value is increased from 1.475 to 2.181. Conclusions: Application of Six Sigma management method could reduce the defect rate of in-patient nursing records in routine care.