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护理书写质量管理系统的构建与应用
引用本文:刘军,谢陈漪.护理书写质量管理系统的构建与应用[J].护理学杂志,2017,32(11).
作者姓名:刘军  谢陈漪
作者单位:复旦大学附属华山医院北院护理部 上海,201907
摘    要:目的开发和使用基于信息化的护理书写质量管理系统,提高护理书写质量。方法设计基于信息化的护理书写质量管理系统,采取自查、科查和部查每个月对病区护理书写质量进行检查。结果运行护理书写质量管理系统后,护理书写质量得分显著高于运行前,护理书写质控检查各环节耗时显著少于运行前(P0.05,P0.01)。结论应用护理书写质量管理系统进行护理书写质量管理,可提高护理书写的准确率、缩短临床护理书写质控时间,提高护理质控效率。

关 键 词:护理文件书写  护理质量管理系统  信息管理

Establishment and application of IPAD-assisted nursing documentation quality checking system
Liu Jun,Xie Chenyi.Establishment and application of IPAD-assisted nursing documentation quality checking system[J].Journal of Nursing Science,2017,32(11).
Authors:Liu Jun  Xie Chenyi
Abstract:Objective To develop an IPAD-assisted nursing documentation quality checking system,and to improve the quality of nursing documents.Methods We developed an IPAD-assisted nursing documentation quality checking system and fostered 3 kinds of checking methods(self-checking by unit quality inspectors,division checking by nurse managers,and nursing-department-led checking) to meticulously scrutinize nursing documents every month.Results After application of the IPAD-assisted nursing documentation quality checking system,the scores of nursing documents were significantly enhanced,and the time it took for quality checking processes was significantly shortened (P< 0.05,P< 0.01).Conclusion Application of the IPAD-assisted nursing documentation quality checking system can improve the correctness of nursing documents,reduce the time of quality checking,and improve the efficiency of quality control.
Keywords:nursing documentation  quality checking system  information management
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