护理记录书写质量控制的方法与效果

The practice and effect of three-level quality control system on the quality of nursing records

目的减少护理记录书写缺陷的发生,提高护理记录书写质量。方法对护士进行护理记录书写培训;对护理记录实施纵向、横向质量控制法;实施三级质量控制:一级白班护士、二级夜班护士、三级护士长,全员参与护理记录质量控制。结果护理记录缺陷检出率一级质量控制由8.00%提高到18.00%,二级质量控制由12.00%提高到22.00%,提高了护理记录的终末质量,三级护士长质量控制护理记录缺陷率由45.33%下降到8.00%,护理部质量控制护理记录缺陷率由11.33%下降到4.67%,差异均具有统计学意义(P<0.01或P<0.05)。结论全员参与质量控制可以提高护理记录的终末质量。

Objective To reduce the defects of nursing records and improve the quality of nursing documents. Methods The measures included providing training of nursing records for nurses, practicing transverse and longitudinal quality control with three - level system including day - shift nurses, night - shift nurses and head nurses to make all the nursing staff participate in the quality control of nursing records. Results The detected rate of nursing records defects was increased frmn 8.00% to 18.00% by the first - level quality control （ day - shift nurses） ,and from 12.00% to 22.00% by the second - level quality control （ night - shift nurses） ,which improved the terminal quality of nursing records. As a result,the detected rate of nursing records defects was reduced from 45.33% to 8.00% by the thirdlevel quality control （head nurses） , and the rate of nursing records defects was reduced from 11.33% to 4.67% in the quality control by nursing department. Conclusion The overall participation of quality control can improve the terminal quality of nursing records.