精神科出院护理病历质量控制措施探讨

The research on the quality control of the nursing case history of the patients in Psychiatric Department

目的探索提高精神科出院护理病历书写质量的有效控制措施。方法自制调查表,由经过统一培训的护理考核组人员对新的护理病历缺陷控制措施实施前后的出院护理病历进行调查,所有资料经χ2检验进行统计学分析。结果新的护理病历缺陷控制措施实施前后护理病历缺陷包括基本情况漏项,涂改、错字,护理文件自相矛盾,医护记录不符,护理记录与医嘱不吻合,执行医嘱不及时,有护理问题无措施等。经χ2检验差异均有统计学意义(P<0.05),护理记录与病情不吻合差异无统计学意义(P>0.05)。结论不断完善护理病历质量控制措施能减少护理病历缺陷,提高护理病历的质量。

Objective To explore the effective control measures to heighten the out--patients＇ nursing casehistory quality in psychiatric department. Methods By slfe--made questionnaire, the group of special--trained nurses inquired the new case history disfigurement on nursing control measures before or after the application,and all the data were statistically analyzed by Х^2 method. Results Before or after the new case-history disfigurement on nursing control measures was conducted,the defects were involved in some basical conditions flaw,alter,misprint, the case-history antinomy,medical record disagree with the doctor＇s advices,and delayed conduction of the doctors＇ instructions, etc. There are statistic meanings through Х^2 test, and the difference is evident （P〈0.05）, while the disaccord between the nursing record and illness is not evident （P〉0.05） . Conclusion To improve the quality control measures on nursing case-history gradually can reduce the nursing flaws and enhance the nursing case-history quality.