CAJ | 학술논문

目的：探讨持续质量改进在护理文件书写质控中的应用效果，对护理文件书写质量实施全程监控，提高护理文件书写质量。方法各科室成立质量管理小组、护理部成立护理文件质控组，对护理文件书写质量进行全程有效监督和指导。将2013年8-12月1251份归档病历作为观察组，2012年9月-2013年1月1162份归档病历作为对照组进行缺陷发生情况比较。结果观察组中体温单、医嘱单、出入院评估单、护理记录单缺陷率分别为4．40％，2．80％，4．16％，13．11％，均明显低于对照组11．53％，9．03％，15．49％，35．80％，差异均有统计学意义（χ2值分别为42．487，42．898，84．873，160．424；P＜0．01）。体温单、出入院评估单、医嘱单在观察组中每项缺陷率均低于对照组，差异有统计学意义（P＜0．01），在护理记录单中绝大部分问题的发生率观察组较对照组明显降低，个别问题的发生率两组比较差异无统计学意义（P＞0．05）。结论科室护理文件质控管理小组及护理部质控组对护理文件书写的全程管理发挥了重要作用，提高了护理文件书写质量。
목적：탐토지속질량개진재호리문건서사질공중적응용효과，대호리문건서사질량실시전정감공，제고호리문건서사질량。방법각과실성립질량관리소조、호리부성립호리문건질공조，대호리문건서사질량진행전정유효감독화지도。장2013년8-12월1251빈귀당병력작위관찰조，2012년9월-2013년1월1162빈귀당병력작위대조조진행결함발생정황비교。결과관찰조중체온단、의촉단、출입원평고단、호리기록단결함솔분별위4．40％，2．80％，4．16％，13．11％，균명현저우대조조11．53％，9．03％，15．49％，35．80％，차이균유통계학의의（χ2치분별위42．487，42．898，84．873，160．424；P＜0．01）。체온단、출입원평고단、의촉단재관찰조중매항결함솔균저우대조조，차이유통계학의의（P＜0．01），재호리기록단중절대부분문제적발생솔관찰조교대조조명현강저，개별문제적발생솔량조비교차이무통계학의의（P＞0．05）。결론과실호리문건질공관리소조급호리부질공조대호리문건서사적전정관리발휘료중요작용，제고료호리문건서사질량。
Objective To explore the application effect of continuous quality improvement in the quality control of nursing documentation , and carry out the whole monitoring of the quality of writing nursing documentation so as to improve the quality of nursing documentation .Methods The groups of quality control of nursing documentation in the departments and the department of nursing were established in order to the effective supervision and guidance of writing nursing documentation in the whole process .One thousand two hundred and fifty-one archived medical records from August 2013 to December 2013 were chosen as the observation group , and 1162 records from September 2012 to January 2013 were chosen as the control group .The incidence of defects was compared between two groups .Results The incidences of defects including the temperature records, doctor’s advice, the admission and discharge evaluation records and nursing records were respectively 4.40%,2.80%,4.16%,13.11%in the observation group, and were 11.53%,9.03%,15.49%,35.80% in the control group, and the differences were statistically significant (χ2 =42.487,42.898,84.873,160.424, respectively;P<0.01).Temperature records, doctor’s advice, the admission and discharge evaluation records in each defect rate in the observation group were lower than the control group , the difference was statistically significant (P<0.01).Incidence rate of most of the problems in nursing records in observation group were lower than the control group , the incidence of individual problems between the two groups has no statistical significance ( P >0.05 ).Conclusions The groups of quality control of nursing documentation in the departments and the department of nursing play important role in the whole process management of writing nursing documentation so as to improve the quality of nursing documentation .