两卫生条例实施前后精神科护理记录质量的比较

目的探讨《医疗事故处理条例》及《上海市精神卫生条例》（以下简称两《条例》）实施前、后精神科护理记录质量的变化。方法随机抽查我院2001年1-6月份及2006年1-6月份两《条例》实施前、后各50份住院病人护理记录进行对照。根据两《条例》、卫生部《病历书写基本规范》（试行）的评价标准，结合上海市精神科护理质量控制内容和我院实际情况制定《护理书写标准册》作为检查标准。结果两《条例》实施前、后护理记录比较，结果提示：实施后护理记录在客观性、正确性、及时性、完整性、针对性护理措施落实和康复指导等方面均有显著性差异（P〈0．05）。结论两《条例》的实施对护理记录质量的提高有很大的帮助。

Psychiatric Nursing record quality analysis before and after two health laws issued

Objective: To compare the psychiatric nursing record quality before and after "Malpractice Act" and"Shanghai Mental Health Law" (hereafter are referred to as two laws) implemented. Methods: 100 nursing records were randomly obtained, with 50 records each from the patients hospitalized in the period from January 2001 to June 2001 and from January 2006 to June 2006 before and after two laws issued respectively. The quality measurement indicators were based on two laws, "Medical Records Basic Norms"(Ministry of Health, the evaluation version), Shanghai psychiatric nursing quality controls, and hospital nursing record standards. Results:Before and after two laws implemented, the record objectivity, accuracy,timeliness, integrity,specific nursing, and rehabilitation counseling were statistically significantly different (P <0.05). Conclusion:Two laws implementations have played an important role in nursing record quality improvement.