护理病历质控小组在提高护理记录质量中的作用

目的:探讨护理病历质控小组在护理记录中的质量控制作用,提高护理记录的书写质量。方法:随机选择2010年10月份住院病历200份为对照组,本组未进行质控。随机选择2011年1月住院病历200份为实验组,质控小组对本组病历反复检查,找出存在问题,分析原因,提出改进措施。两组资料均为危重或发生病情变化住院1周以上患者的病历。结果:通过质控小组的质控,实验组的护理记录缺陷发生率明显低于对照组(P<0.01)。结论:质控小组对护理记录单书写质量的提高起到了关键的作用,确保了护理记录质量。

Effect of quality control group of nursing medical records on improving quality of nursing records.

Objective ：To investigate the effect of quality control group of nursing medical records in quality control of writing nursing records, and improve the quality of nursing records. Methods：Two hundreds medical records were randomly selected as the control group. The quality control group examined the medical records repeatedly analyzed the causes of the problem and proposed improving measures. Another two hundreds medical records in January 2011 were randomly selected as the experimental greup,and each of them accepted quality control examination. All the patients in the two groups were critical and serious cases or had been staying in hospital more than a week because of progress of disease. Results ：Through quality control, the defect rate of nursing re cords of experimental group is obviously lower han the control group（P 〈0.01 ）. Conclusion：Quality control group of nursing medical records plays a key role on improving the quality of nursing records,and ensures the quality of nursing records.