电子版内外科疾病护理指南在护理病历质量控制中的应用

Application of Electronic Form of Internal Medicine and Surgical Nursing Guide in Quality Control of Nursing Medical Record

目的探讨《电子版内外科疾病护理指南》在护理病历质量控制中的应用效果。方法制定《电子版内外科疾病护理指南》,先调查确定疾病目录,请专科护理专家确定其知识框架,对各医院专科护理组长进行培训,查阅指定的国内外权威书籍和文献,收集、归纳、概括专科护理要点,然后经专科护理专家进行修改及审核后完成手稿,然后在电脑工程师协助下,制作成关于各科护理技术指引的专业数据库,通过计算机及网络实现多科室信息资源共享。抽检《电子版内外科疾病护理指南》使用前后护理病历存在的问题。结果抽检使用前(2008年)376份和使用后(2009年)392份病历中,护理病历书写缺陷由2008年的0.83处/份,下降到2009年的0.61处/份,经检验χ2=12.08,P<0.05,差异有统计学意义,其中2009年入院评估缺项或不符、记录术语欠规范、缺针对性护理措施、评估欠连续性等方面缺陷较2008年都有所下降(P<0.05),但缺安全隐患预见性记录没有明显差异(P>0.05)。结论《电子版内外科疾病护理指南》的使用,提高了护理人员的评估能力;规范了记录中的专业术语;提高了针对性护理措施的执行力;护理记录和病情评估的连续性加强,提高了全体护理人员的护理病历书写质量。

Objective To discuss the application of the Electronic Form of Internal Medicine and Surgical Nursing Guide in quality control of nursing medical record.Methods The Electronic Form of Internal Medicine and Surgical Nursing Guide was made then shared by all departments.Problems existing before and after the application of the electronic form were collected and analyzed.Results Writing defects existing in nursing medical record lowered from 0.83 to 0.65 spot per record（χ2=12.08,P0.05）.And the incidence of other defects lowered as well（P0.05）,except the predictability record of safety risks（P0.05）.Conclusion Evaluation competence of nursing staff is improved with the application of the electronic form.Term recording is standardized,nursing recording and disease evaluation are enhanced as well.