| 护理文书全程监控的质量分析 |
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| 引用本文： | 聂翠华,田玉莲.护理文书全程监控的质量分析[J].中国病案,2012,13(5):26-28. |
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| 作者姓名： | 聂翠华 田玉莲 |
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| 作者单位： | 新疆省乌鲁木齐市精神病福利院,乌鲁木齐市,830023 |
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| 摘 要： | 目的构建精神科护理文书全程监控的管理模式,保障护理文件书写质量,为患者提供优质护理服务。方法将2009-2010年487份出院病历分为对照组及全程监控组,对存在缺陷进行分析。结果实施全程监控后,与对照组相比,护理记录中的缺陷频数减少了54项,两组的共性问题缺陷频数减少了57项,同时增强护理人员的法律证据意识及慎独精神,提升业务能力及素养,提高全员参与的主动性、积极性,提高护理记录水平。结论全程监控能有效提高护理文书的书写质量,促使护士规范医疗行为的养成,起到有效预防医疗纠纷的作用。
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| 关 键 词： | 全程监控 精神科 护理文书 |
Quality Analysis on Whole-course-monitor of Nursing Document |
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| Nie Cuihua
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Tian Yulian.Quality Analysis on Whole-course-monitor of Nursing Document[J].Chinese Medical Record,2012,13(5):26-28. |
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| Authors: | Nie Cuihua Tian Yulian |
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| Institution: | ,Urumqi Welfare Institution of Mental Disease,Urumqi 830023,Xinjiang Hui Minorities Autonomous Region,China |
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| Abstract: | Objectives This paper constructs management mode of whole-course-monitor in nursing document and protects writing quality of nursing document for providing well quality nursing service for patients.Methods 487 hospitalization medical records are divided into comparison group(CG) and whole-course-monitor group(WCMG) from 2009 to 2010 had analyzed the existing defects.Results Compared to CG,after whole-course-monitor,defects frequency in nursing records decrease 54 items in WCMG.The defects frequencies of common problems in two groups decrease 57 items.Nurses should strengthen their legal evidence consciousness and caution when individual work and improve professional ability and quality,improving their initiative and enthusiasm and nursing record level.Conclusions The whole-course-monitor can effectively improve writing quality of nursing document and urging their development of standard medical behavior,playing role of effectively preventive medical tangle. |
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| Keywords: | Whole-course-monitor Psychiatric department Nursing document |
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