电子护理病历质量监控方法与体会

Implementation and experience of the quality management of electron case records

目的探讨数字化医院模式下电子护理病历质量的监控方法。方法建立责任主管-护士长-护理部质量控制组的三级质量控制链,对护理病历从书写、环节、终末、反馈质量4个环节进行动态监控和管理,形成多渠道、全方位,层层把关、环环检查的"链式"检查体系。结果电子护理病历达到了规范统一,为护理教学、科研提供了依据。结论 "链式"质量监控法可以保障电子护理病历的质量。

Objective To explore the dynamic quality monitoring methods of electron case records in digital hospitals. Methods A throe - level quality management chain including nurses in charge - head nurses - quality control group of nursing department was established to dynamically monitor and manage the four links of nursing documents ：writing, process,outcome, and quality feedback,which formed a multi - channel and all - round chain check system. Result The electron case records reached an uniform standard and could provide the reliable for nursing teaching and research. Conclusion The chain check management method can ensure the quality of electron case records.