住院病历护理文书质量管理的提高与改进

Persist in the Continuous Improvement Raise the Quality of Nursing Document Writing

目的:提高全院护理文书书写质量,减少乙级病历,杜绝丙级病历发生。方法:制定本院《临床护理文书质控方案》,对全院护理文书进行检查,按照本院《临床护理文书质量评价标准表》逐一进行对照检查,评分定级。结果:725份归档病历中,甲级病历715份,乙级病历10份,丙级病历0份,病历合格率达98.6﹪。结论:重视护理文书书写,加强督促和检查病历力度可提高护理文书书写质量,减少乙级病历,杜绝丙级病历发生。

Objective： To reducing B record and preventing C record,that improve the quality of Nursing document writing.Method： Formulating the document of ＂Scheme of control over Clinical-Nursing document＂.Inspecting the Nursing document writing over all and standard with the ＂Scheme of control over Clinical-Nursing document＂ to assess levels.Result： In the sample of 725 Medical records,there are 715 A records,10 B records and without C record.The percentage of pass is 98.6%.Conclusion： Attaching importance to Nursing document writing and enhance supervising Medical records can improve the quality of Nursing document writing then reduce B record and prevent C record.