中国护理管理
中國護理管理
중국호리관리
Chinese Nursing Management
2015年
10期
1234-1236
,共3页
王华芬%郑亚萍%黄鑫%汪四花
王華芬%鄭亞萍%黃鑫%汪四花
왕화분%정아평%황흠%왕사화
医院评审%标准%护理病历%完整性%查检工具
醫院評審%標準%護理病歷%完整性%查檢工具
의원평심%표준%호리병력%완정성%사검공구
hospital accreditation%standard%nursing records%completeness%checking tool
目的：设计和应用护理病历完整性查检工具，以提高护理病历质量和管理实效。方法：根据JCI医院评审标准的患者评估及病历质量测量要素以及稽查方法，结合临床工作的实践经验，设计了护理病历完整性查检工具。其查检项目包括护理初始评估和再评估、健康教育评估、护理计划4个一级指标以及24个二级指标；每月由护理病历质控专家抽取每个护理单元5%～10%的运行病历，查检结果采用“是、否、不适用”三个层级进行评判。结果：应用护理病历完整性查检工具后，护理病历总体完整率提升了2.77%，与应用前比较差异有统计学意义（P<0.05）；护理再评估、健康教育评估、护理计划记录完整率分别提高3.59%、2.25%、9.12%，与应用前比较差异均有统计学意义（P<0.05）。二级指标的约束评估、特殊检查/治疗、护理诊断、诊断相关因素、护理目标达成时间的记录完整率分别提高了15.83%、17.04%、22.25%、16.05%、8.42%，与应用前比较差异均有统计学意义（P<0.01）。通过对护理病历完整性查检工具使用的评价显示，对一级指标项目内容设计满意度分别为96.0%、92.0%、90.0%、90.0%；对“是、否、不适用”评价方式的认可度为90.0%；认为其能提高护理病历完整性作用的占92.0%；查检单份病历平均耗时缩短了49.4%。结论：应用护理病历完整性查检工具进行护理病历完整性稽查，简便高效，能提高护理病历质量，从而提升临床护士整体照护能力。
目的：設計和應用護理病歷完整性查檢工具，以提高護理病歷質量和管理實效。方法：根據JCI醫院評審標準的患者評估及病歷質量測量要素以及稽查方法，結閤臨床工作的實踐經驗，設計瞭護理病歷完整性查檢工具。其查檢項目包括護理初始評估和再評估、健康教育評估、護理計劃4箇一級指標以及24箇二級指標；每月由護理病歷質控專傢抽取每箇護理單元5%～10%的運行病歷，查檢結果採用“是、否、不適用”三箇層級進行評判。結果：應用護理病歷完整性查檢工具後，護理病歷總體完整率提升瞭2.77%，與應用前比較差異有統計學意義（P<0.05）；護理再評估、健康教育評估、護理計劃記錄完整率分彆提高3.59%、2.25%、9.12%，與應用前比較差異均有統計學意義（P<0.05）。二級指標的約束評估、特殊檢查/治療、護理診斷、診斷相關因素、護理目標達成時間的記錄完整率分彆提高瞭15.83%、17.04%、22.25%、16.05%、8.42%，與應用前比較差異均有統計學意義（P<0.01）。通過對護理病歷完整性查檢工具使用的評價顯示，對一級指標項目內容設計滿意度分彆為96.0%、92.0%、90.0%、90.0%；對“是、否、不適用”評價方式的認可度為90.0%；認為其能提高護理病歷完整性作用的佔92.0%；查檢單份病歷平均耗時縮短瞭49.4%。結論：應用護理病歷完整性查檢工具進行護理病歷完整性稽查，簡便高效，能提高護理病歷質量，從而提升臨床護士整體照護能力。
목적：설계화응용호리병력완정성사검공구，이제고호리병력질량화관리실효。방법：근거JCI의원평심표준적환자평고급병력질량측량요소이급계사방법，결합림상공작적실천경험，설계료호리병력완정성사검공구。기사검항목포괄호리초시평고화재평고、건강교육평고、호리계화4개일급지표이급24개이급지표；매월유호리병력질공전가추취매개호리단원5%～10%적운행병력，사검결과채용“시、부、불괄용”삼개층급진행평판。결과：응용호리병력완정성사검공구후，호리병력총체완정솔제승료2.77%，여응용전비교차이유통계학의의（P<0.05）；호리재평고、건강교육평고、호리계화기록완정솔분별제고3.59%、2.25%、9.12%，여응용전비교차이균유통계학의의（P<0.05）。이급지표적약속평고、특수검사/치료、호리진단、진단상관인소、호리목표체성시간적기록완정솔분별제고료15.83%、17.04%、22.25%、16.05%、8.42%，여응용전비교차이균유통계학의의（P<0.01）。통과대호리병력완정성사검공구사용적평개현시，대일급지표항목내용설계만의도분별위96.0%、92.0%、90.0%、90.0%；대“시、부、불괄용”평개방식적인가도위90.0%；인위기능제고호리병력완정성작용적점92.0%；사검단빈병력평균모시축단료49.4%。결론：응용호리병력완정성사검공구진행호리병력완정성계사，간편고효，능제고호리병력질량，종이제승림상호사정체조호능력。
Objective:To improve the quality of nursing records and management effectiveness through design and application of the nursing records completeness checking tool. Methods:According to JCI accreditation standards for patients' assessment and medical records quality measuring elements, combining their clinical work experience, the authors designed the nursing records completeness checking tool. It included four primary indicators, named initial nursing evaluation, re-evaluation, health education assessment, and care plan;and 24 secondary indicators. About 5%-10%of the operating records of each nursing unit were extracted and checked monthly by a quality control specialist. Three level results named"yes, no, or not applicable (NA)"were used for the evaluation. Results:The nursing records complete rate increased 2.77%(P<0.05) after using the nursing records completeness checking tool. Nursing reassessment, health education assessment and care plan record completeness increased 3.59%, 2.25%and 9.12%, respectively (P<0.05). Record completeness of secondary indicators, including constraint assessments, special examination/treatment, nursing diagnosis, diagnosis-related factors, and the nursing goal achieving time record, increased 15.83%, 17.04%, 22.25%, 16.05%, and 8.42%, respectively (P<0.01). The evaluation of nursing records completeness checking tool application showed that the satisfaction on four primary indicators design was 96.0%, 92.0%, 90.0%, and 90.0%. The recognition degree of"Yes, No, NA"judgment methods was 90.0%;and 92.0%nurses believed that it could improve the completeness of the nursing records. The average checking time for one set of nursing records shortened 49.4%compared with before. Conclusion:Application of nursing records completeness checking tool could effectively improve the quality of nursing records.
