CAJ | 학술논문

目的：探讨PDCA循环结合RCA分析法对护理病历书写实施质控管理的实践效果。方法：2012年8月开始运用 PD-CA循环结合RCA分析法对病区的护理病历书写实行环节质控管理。每1个月为一轮PDCA循环，护理病历质控小组月初到2个科室随机抽取病历各5份，按《卫生部病历书写规范》和《广东省临床护理文书规范(专科篇)》建立《护理病历质量评价标准》对体温单、首次护理评估单、护理记录单及各种专科护理单进行环节评价，把检查中存在的问题运用RCA方法从人、机、物、环、法等方面进行分析；月中组织相关人员进行反馈及针对书写存在的问题进行培训；月底对所抽查的病历进行终末评价。结果：按住院号的顺序随机抽取2012年8月~2013年7月和2011年8月~2012年7月归档病历各120份，按前述标准重新评价护理文书质量，比较书写缺陷发生率，实践后护理文书缺陷发生率较实践前明显降低，差异有统计学意义(P<0.05)。结论：运用 PDCA 循环结合 RCA 方法提升了护理人员的书写水平，确保护理病历的真实性、客观性、准确性、规范性和完整性，能有效地减少护理文书书写缺陷。
목적：탐토PDCA순배결합RCA분석법대호리병역서사실시질공관리적실천효과。방법：2012년8월개시운용 PD-CA순배결합RCA분석법대병구적호리병역서사실행배절질공관리。매1개월위일륜PDCA순배，호리병력질공소조월초도2개과실수궤추취병력각5빈，안《위생부병역서사규범》화《광동성림상호리문서규범(전과편)》건립《호리병력질량평개표준》대체온단、수차호리평고단、호리기록단급각충전과호리단진행배절평개，파검사중존재적문제운용RCA방법종인、궤、물、배、법등방면진행분석；월중조직상관인원진행반궤급침대서사존재적문제진행배훈；월저대소추사적병력진행종말평개。결과：안주원호적순서수궤추취2012년8월~2013년7월화2011년8월~2012년7월귀당병력각120빈，안전술표준중신평개호리문서질량，비교서사결함발생솔，실천후호리문서결함발생솔교실천전명현강저，차이유통계학의의(P<0.05)。결론：운용 PDCA 순배결합 RCA 방법제승료호리인원적서사수평，학보호리병력적진실성、객관성、준학성、규범성화완정성，능유효지감소호리문서서사결함。
Objective:To explore the effect of PDCA with RCA in the practice of nursing documents quali-ty control management.Methods:Began in August 2012 using PDCA and RCA of ward nursing management of medical record writing practice link quality control.Per a month for the round of PDCA cycle,Nursing re-cords quality control team in early to 5 copies of 2 randomly selected medical record department,According to the《Ministry of health record writing standard》and《Guangdong Province clinical Nursing document spec-ification (college essay)》the Establishment of Our hospital 《nursing records quality evaluation criteria》for temperature,for the first time nursing assessment,nursing records and various single nursing is part of eval-uation,To check the problems existing in the use of RCA methods from man,machine,material,ring,the respect such as method of analysis;Organize relevant personnel,in the middle of the training feedback and aiming at the problems of writing;Terminal evaluation by spot check of the end of the medical records.Re-sults:According to the hospital the order of the random number in August 2012-July 2013 and August 2011-July 2012 120 copies of archival records,According to the standard to evaluate the quality of nursing docu-ments,Compare writing incidence of defects,After the practice nursing documents significantly lower inci-dence of defects before the practice,The difference was statistically significant (P<0.05).Conclusion:Using PDCA and RCA improved the nurses'level of writing,To ensure the authenticity of nursing records,obj ectiv-ity,accuracy,the standardization and integrity,Defects can effectively reduce the nursing documents writ-ing.