护理记录的质量分析与管理对策

Analysis of the quality of nursing records and its managing measures

目的分析现有护理记录质量,规范临床医疗护理行为,保障护理安全。方法抽查我院2006年1月—2007年11月住院、归档病历共1183份,对护理文件记录进行评分。结果①各项护理文件记录的质量分析,扣分率以医嘱单和一般患者护理记录最高,危重患者护理记录为最低;缺陷率以一般患者护理记录和体温单最高,危重患者护理记录最低。②一般患者护理记录中各类记录的质量分析,扣分率是一般护理记录最高,入院护理评估表最低;缺陷率是一般护理记录最高,入院护理评估表为最低。结论加强护理文件书写规范与质量标准的培训学习,对提高护理文件记录的质量内涵、维护医患双方权益均起着重要的作用。

Objective To standardize clinical nursing precedure and ensure safe nursing. Methods One thousand and one hundred eight three inpatient＇ s pigeonholed medical records from January 2006 to Novemder 2007 were spot-checked for quality evaluation. Results 1. With regard to quality of the various nursing files, the highest rate of score deduction was found in the medical order sheet and in the nursing records of ordinary patients, while the lowest rate was shown in the nursing records of critical patients. The highest defect was shown in the nursing records of ordinary patients and in the temperature sheets, the lowest rate was in the nursing records of critical patients. The X： test showed significance in the comparison of defect. 2. With regard to quality analysis of the various kinds of nursing records of ordinary patients, the highest rate of score deduction was in the general nursing records, while the lowest rate was shown in the admission nursing evaluation sheets. The highest defect was in the general nursing records, the lowest was in the admission evaluation sheets. Conclusion The training of writing standardized high quality nursing material is important to improve the quality of nursing records and protect the rights and interests of both medical worker and patients.