终末病案护理文书质量对比分析

目的加强护理文书质量控制,提高护理文书书写质量,保证护理安全。方法随机抽取2010年12月-2011年2月出院归档病案545份,对照我院护理部下发的护理文书书写考核评分标准进行质量检查,对存在的质量缺陷在护士长例会上进行反馈,分析原因,提出改进措施,1年后再随机抽取2011年12月-2012年2月出院病案569份进行检查。结果缺陷病案率由53.8%降至16.9%（P〈0.05）,总缺陷点由562个降至128个（P〈0.05）。结论通过加强护士法律意识及护理文书书写能力的培训教育,重视护理文书的环节质控,实施护理文书表格化,增加护理人力资源,终末病案护理文书质量有了较大提高,保证了护理安全。

The Comparison Analysis of Nursing Records Quality of Final Medical Records

Objectives to strengthen quality control of nursing records and writing quality for ensur/ng nursing safety. Methods 545 medical records discharged from Nov. 2010 to Feb. 2011 were randomly sdected had checked according to nursing record writing evaluation standard issued by depart- ment of nursing in our hospital. The existing quality defects should be pointed out at the regular meeting of head nurses with analyzing reasons and putting forward improvement countermeasures. 569 medical records discharged from Nov. 2011 to Feb. 2012 are checked. Results The defects rate ofmedical records reduce from 53.8% to 16.9% （ P 〈 0.05 ） ; the total defects points reduce from 562 to 128 （ P 〈 0.05 ）. Conclusions The nursing record quality of final medical records gret~tly improves and ensures nursing safety by nurses＇ legal consciousness and training education of nursing record writing ability strengthening, value on segment quality of nursing document, implementation of nursing table record and nursing human resource in-