持续改进在护理文书三级质控中的应用

Application of continuous improvement in the tertiary quality control of nursing document

目的:探讨提高病区护理文书质控的方法,进一步提高护理文书书写质量。方法:采用2009年3月～2010年8月进行三级护理文书质控的归档病历中随机抽取300份作为观察组,2009年3月以前进行传统方法质控的归档病历中随机抽取300份作为对照组,对两组病历的基本要求、体温单、医嘱单、首次护理记录单、护理记录单等5项内容缺陷进行分析比较。结果:观察组缺陷明显少于对照组,差异有统计意义(P<0.05)。结论:护理文书的三级质控,能够有效的提高护理文书的质量,避免因护理文书写引起的法律纠纷,是质量管理在护理文书管理中的具体应用,是对护理文书质量实行持续改进的有效方法。

Objective： To explore the method to improve the quality control of nursing documents and to enhance the quality of nursing documents writing. Methods： The three-level quality control of nursing documents written from March 2009 to August 2010 were adopted as the study group, the traditional method quality control of nursing documents written before March 2009 were adopted as the control group, 300 documents were randomly selected from each group. The 5 sides of defects of the two groups in basic requirements, temperature chart, medical orders, the first nursing record sheets, nursing record sheets were analyzed and compared. Results： The defects in the study group were less than those in the control group, the differences were significant （P〈0.05）. Conclusion： The three-level quality control can effectively enhance the quality of nursing documents and avoid legal disputes. It＇s the specific application in quality management and effective methods of continuous improvement.