自行设计病历质控检查表在护理病历持续质量改进中的效果研究

The effect of self-designed records quality control check list in improving continuously quality of nursing records

目的 落实医疗制度,保障医疗安全,防范医疗风险,分析护理病历中存在的主要缺陷,探讨一种提高病区护理病历质量的有效方法.方法 自行设计病历质控检查表应用于临床工作中,抽查我院已提交部分病历4 180份,将传统方法的对照组病历（2009年前）和观察组病历（2009年后）进行对照分析.结果 根据病历书写基本要求,观察组缺陷病历明显少于对照组病历,差异有统计学意义（P〈0.01）.结论 病历质控检查表可把病历缺陷消灭在病历的形成过程中,达到病案质量监控效果的最大化,是全面质量管理在病历管理中的具体应用,是对护理病历质量实行持续改进的有效方法.

Objective To analyze the main defects in the nursing records, explore an effective method to improve the quality of nursing records.Methods A total of 4 180 records copies were selected. Before 2009 of those as control group were examined with routine method, while after 2009 of those as observation group were examined with self-designed records quality control check list. The results were compared.Results According to the nursing records writing basic requirements , the difference was statistically significant（P〈0.01） ,and defects in observation group were obviously less than those in control group.Conclusions Using this list can eliminate defects in forming the nursing records process. It is an effective method of improving continuously the quality of nursing records.