医药前沿
醫藥前沿
의약전연
YIAYAO QIANYAN
2013年
29期
109-110
,共2页
护理记录%持续改进%分析与控制
護理記錄%持續改進%分析與控製
호리기록%지속개진%분석여공제
Nursing record handwriting%Constantly improve%Analysis and control
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
目的：加彊護理書寫質量分析與控製，提高書寫質量，減少法律隱患。方法隨機抽查2012下半年和2013年上半年的全院各科在架病歷各280份的護理書寫質量進行對比，2012年下半年為對照組，2013年上半年為觀察組，在此基礎上，護理部2013年質量規劃加彊瞭護理書寫的質量鑑管力度及改進瞭質控方法。結果將兩組護理書寫質量分彆進行比較，觀察組在醫學術語的規範性、記錄的連貫性、疾病的專科特色、健康教育的完善、安全防範措施的落實等方麵，明顯優于對照組，閤格率提高瞭1.2%，護理書寫質量明顯提高。結論通過對護理記錄進行檢查、分析，持續改進其中缺陷，提高瞭書寫質量，同時提升瞭護士職業素質
목적：가강호리서사질량분석여공제，제고서사질량，감소법률은환。방법수궤추사2012하반년화2013년상반년적전원각과재가병력각280빈적호리서사질량진행대비，2012년하반년위대조조，2013년상반년위관찰조，재차기출상，호리부2013년질량규화가강료호리서사적질량감관력도급개진료질공방법。결과장량조호리서사질량분별진행비교，관찰조재의학술어적규범성、기록적련관성、질병적전과특색、건강교육적완선、안전방범조시적락실등방면，명현우우대조조，합격솔제고료1.2%，호리서사질량명현제고。결론통과대호리기록진행검사、분석，지속개진기중결함，제고료서사질량，동시제승료호사직업소질
Aims:To strengthen the analysis and control of the quality of the nursing record handwriting, to improve the quality of the nursing record handwriting, and hence to reduce the disputes between the hospital and the patients Approaches: Out of the the second half of 2012 and the first half of 2013 on-shelf medical records of the whole hospital, randomly spot check 280 copies separately and make a comparison between them, the former year records being compared group,and the latter being observed group.Furthermore,the nursing department, in the quality management planning for 2013, strengthened the analysis and control of the quality of the nursing recording handwriting and improved the quality of the nursing recording handwriting.Results:After individual y comparing the quality between the two groups’nursing recording handwriting, the observed group are found to be obviously better than the compared group, in the aspects such as the specifications of medical terms, continuity of records, specialist features of diseases, the perfection of health education and the implementation of safety precautions, with the pass rate up by 1.2% and the quality of recording handwriting significantly improved.Conclusion:By checking, analyzing the nursing record handwriting, and constantly correcting the defects , we have improved the nursing record handwriting and enhanced the nurses’ professional quality.
