基层医院危重病人护理记录存在问题的分析和对策

Analysis and strategy of existing problem on nursing record of critical patient in primary hospital

目的:通过对我院危重病人护理记录单的回顾性调查,分析存在的问题,提出针对性的整改措施,以提高护理质量。方法:整改前抽查危重病人护理病例600份,针对其存在的问题加强质控管理,整改后抽查612份危重病人护理病例,对两组病例存在的问题进行比较,并进行统计学分析。结果:两组比较差异有显著性,整改后护理记录质量明显提高(P<0.05),结论:有针对性的,多元化的管理是提高危重病人护理记录质量的保障。

objective：To analyze existing problem,propose rectif ication measures and improve the quality of care by retrospectively investigating to nursing record of critical patient in my hospital.Method：To draw randomly 600 cases of critical patient before rectif ication measures was Implemented and 612 cases of critical patient after rectif ication measures was Implemented,and observe and analyze statistically difference of two groups.Result：Difference of two groups is signif icant.nursing record is improve notablely.Conclusion：Aimed,diversif ied management is important to improve the quality of nursing record on critical patient.