摘要
目的针对护理文件书写存在的缺陷,进行规范管理,从而提高护理文件书写质量。方法规范管理前抽查护理书写病历726份,对缺陷采取的措施有设立护理书写抽查登记本、成立质控小组、制订扣分标准等,规范管理后抽查护理书写病历730份,对缺陷进行对比,并进行统计学分析。结果规范管理后护理文件书写质量明显提高(P<0.01),前后比较差异有显著性。结论加强质控管理是保证护理文书质量的关键。
Objective According to the standardized management in allusion to the existent defect in the nursing document, thus to improve the nursing document writing quality. Methods To spot- check 726 nursing record before standardized management, the adopted measure includes establishing the spot- checking notebooks , to establish the quality control group and constitute the deduct mark standard etc., to make spotcheck 730 nursing case record behind standardized management, carry on the contrast to the defect, and carry on statistics analysis. Results The quality of nursing document writing improved obviously （ P 〈 0.01 ） after standardized management. Difference is remarkable to make a cross- reference,Conclusions Strengthenhag quality control is a key to guarantee the nursing document.
