儿科护理病历缺陷分析与质量控制

目的：通过对儿科护理病历存在的缺陷和问题进行分析,提出相应质控措施,提高病历书写质量与水平。方法：总结归纳在架护理病历与质量检查中护理病历存在的缺陷与问题,从主、客观因素及法律意识等多方面分析产生原因,提出具有较强针对性、可操作的质量改进与控制措施,评价改进效果。结果：合格病历率显著提高。结论：不断总结分析护理病历的缺陷,建立和落实各项改进、控制措施是保证护理病历质量的必须方法。

Analyse defects of nursing case history in paediatrics and its quality contorl

Objective:To analyse the defects and questions of nursing case history in paediatrics,and present relvant measures of quality con- trol,thus to improve quality and level of case history.Method:Summaried defects and questions of case history,analysed the reasons from sub- jective and external factors and law awareness,presented the measures of improvement.Result:The rate of eligibility case history have remark- able improvement,build up and fulil every measures of improvement and control were the essential method to ensure quality of nursing case his- tory.