哈尔滨市综合医院护理文书质量的现状调查

Investigation of the nursing document quality in Harbin general hospitals

目的 通过对哈尔滨市10家综合医院护理文书质量的现状调查,找出护理文书质量存在的问题及产生的原因,并提出相应的改进对策,为医院护理文书质量的可持续改进提供参考.方法 运用整群分层抽样的方法,在哈尔滨市辖区内随机抽取二、三级综合医院各5家,以其普通外科、心内科护理文书作为研究对象,调查2008年11月至2009年5月期间的护理文书909份,其中三级医院外科262份、内科265份;二级医院外科178份、内科204份.采用文献法、现场问卷调查与个人深入访谈相结合的方法进行现状研究,并对数据进行统计学分析.结果 目标医院护理文书质量评价结果显示：三级医院外科、内科护理文书平均分为（97.24±3.08）,（97.26±2.77）分;二级医院外科、内科护理文书平均分为（97.71±2.38）,（98.29±1.94）分;内科护理文书质量二级医院优于三级医院;外科护理文书质量两级医院差异无统计学意义（P＞0.05）.护理文书中危重护理记录单质量最好.护理文书质量存在的主要问题有：刮、粘、涂现象,日期填写错误、内容记录不完整、字迹潦草、血压体重动态变化记录错误.结论 哈尔滨市综合医院护理文书总体质量良好,但还存在一些问题;导致护理文书质量缺陷的主要原因是：护理人员数最不足、法律意识淡漠、责任心不强,护理人员专业素质、文化素质有待提高,医护交流不足、行政监管不够.关键词：护理文书;质量评价;

Objective To find out the defects of nursing documents and the interrelated causes and to propose measures for improvement through investigating the status of nursing documents quality of 10 general hospitals in Harbin, with the aim of providing valuable reference for sustainable improvement of nursing documents. Methods Using stratified sampling method, five secondary general hospitals and five tertiary general hospitals were randomly selected in Harbin. Nursing documents of general surgery and cardiac care were investigated, 909 nursing documents from November 2008 to May 2009 were researched, including 262 documents of surgical department and 265 cases of medical department in tertiary hospitals. Surgical department 178 and medical department 204 in secondary hospitals. Combined literature method, spot field investigation and personal interview , the status were researched, the data were analyzed. Results The nursing documents quality assessment of the objective hospitals showed that： the average scores of surgical departments and medical departments in tertiary hospitals were 97. 20 and 97.26, respectively; scores of surgical departments and medical departments were 97.64 and 98.22 in secondary hospitals. The medical documents qualities of the secondary hospitals were better than the tertiary hospitals＇; The surgical nursing documents qualities had statistical difference. Critical care nursing records had the best quality. The main problems are： scratch, sticky,coating, the wrong date, the content of records are incomplete, illegible handwriting, the wrong records of the dynamics of blood pressure, and so on. Conclusions In general hospital of harbin city, the overall quality of nursing documents are good, but there are still some problems. The main causes of nursing documents defects are the shortage of nurses, awareness of the law, indifferent sense of duty, nurses professional and cultural qualities which need to be improved, lack of health care communication and insufficient administrative supervision.