责任制整体护理模式下的护理记录质量分析

目的 探讨在责任制整体护理模式下护理记录的质量管理,以进一步提高护理记录书写水平,为患者提供更优质的护理服务.方法 将责任制整体护理模式组400份运行病历与传统护理模式组400份运行病历进行缺陷对比分析.结果 实施责任制整体护理后,有缺陷的护理记录从36.25％下降至17.5％;两组对缺陷频数比较,基本书写规范改善最为明显.结论 责任制整体护理模式的运用能降低护理书写缺陷的发生,有效提高护理记录的书写质量.

Analysis of Nursing Records Quality of Responsibility System of Holistic Nursing Model

Objective To discuss the quality management of nursing document with the whole responsibility system nursing mode, further improve the quality of nursing documents writing, provides the high quality nursing service for patients. Methods We analyz- ing the defect of 400 running medical records of responsibility system holistic nursing model group and 400 running medical records of traditional nursing model group. Results The defective nursing documents decreased from 36.25% to 17.5% after the implementa- tion of the responsibility system of the holistic nursing care. The improvement of basic writing standards is the most obvious. Conclu- sion The responsibility system of holistic nursing care can reduce the occurrence of errors in writing, improve the quality of nursing records