护理文书环节质量控制的探讨

目的通过护理文书环节质量检查提高护理文书书写质量。方法由质控处、护理部组织专职护理组长进行护理病案质量随机抽查,每月平均抽查病历200份,对发现的质量问题,在护士长例会上进行反馈,评出前3名及后3名,并按规定给予相应奖励或处分。结果书写质量较《医疗事故处理条例》实施前有了大幅度提高。结论注重环节质量控制,加强护理人员法律意识和业务技能培训,制定相应的奖罚制度并健全病历书写管理制度是提高护理文书书写质量的重要措施。

Focusing on phase quality control improved Nursing Record Integrity

Objective To improve the quality of nursing records writing by analyzing the results of care records quality inspections.Method The quality control department organized full-time head nurse and members of quality control to check 200 pieces of nursing records every month(totally 2400 per year) randomly.The problems would be reported at the regular meeting once a month.The top three would be rewarded while the last three would be punished.Results The quality of writing have improved significantly after the "malpractice bill "came out.However,there were still some problems,such as unclear handwriting,alter,omitted items,nonstandard record,ect.Conclusion Focusing on the phase quality control,enhancing the law awareness,strenthening the training on professional skills,formulating appropriate reward and punishment system,as well as perfecting the rules of writing are all the important measures to improve the quality of nursing writing.