796份护理文书终末质量检查结果分析

The quality analysis of 796 nursing records ending inspection results

目的探讨护理文书在书写过程中存在的问题、产生的原因和防范措施。方法对我院2004年1月-2006年10月期间归档的796份死亡病例护理文书终末质量检查结果进行回顾性分析。结果796份死亡病例中完全符合要求的533份,合格率为66.96%,单项护理文书的总缺陷项次为277项,其中护理记录单缺陷率最高,依次是体温单和医嘱单,分别占缺陷总数的57.76%、23.83%和18.41%。结论护理文书缺陷不能完全避免,但通过护理人员自查自评、自我完善;护理管理者监查补漏;护理部总查、信息反馈等环节控制,可防范和降低护理文书缺陷发生率,提高护理文书书写质量。

To investigate and discuss the reason and predication managerment about nursing recording errors and problems. Methods The ending inspection qualities of 796 death cases nursing cords during January 2004 to October 2006 were reviewed. Results There were 533（66.96%）nursing records accord with request completely in the 796 death cases. The total amount of individual event defect nursing record is 277 items, in which the most were nursing notes writing defects, followed by tempera-ture sheet and doctor＇s advice sheet. They were 57.76%, 23.83% and 18.41% contrating to the sum defect respectively. Conclusion Nursing record defect can not avoid completely, but checking and judging by nursing staff themselves can improve the quality. The nursing supervisors with checking can find other： defects and do some supplement. The nursing department generally checks, information feedback can control the quality and reduce the defect occurrence rate of nursing records, improve nursing record quality.