护理电子病历书写缺陷分析与管理对策

Defect analysis and intervention measures on nursing electronic medical records

目的探讨提高护理电子病历质量的对策。方法按照数字随机表方式,随机抽取本院2012年1月～2013年1月的护理电子病历共计1 000份作为研究对象。分析书写方面出现缺陷次数以及缺陷分布情况。结果 1 000份护理电子病历当中,有816份（81.6%）护理电子病历经检查无缺陷,184份有缺陷（18.4%）;同时184份不规范的护理电子病历当中,最主要的缺陷情况为护理记录不连续,共涉及到76份（41.3%）,分布最少的缺陷为医护记录不一致,共涉及到9份（4.89%）。结论加强对护士的法律意识及护理电子病历书写知识培训,对病历形成环节质量控制,是减少缺陷和提高病历质量的有效方法。

Objective To discuss how to improve the quality of nursing EMR. Methods A total of 1000 nursing electronic medical records from January 2012 to January 2013 were randomly sampled using random number table, and analyzing the writing defect num-ber and defect distribution. Results Among 1000 nursing electronic medical records, 816 cases （81.6%） were found to have no defect after check and 184 cases （18.4%） were found to have defect. The numbers and proportions of defect were significant different be-tween nursing electronic medical record with and without defects. At the same time, the most common defect of 184 copies of non-standard nursing electronic medical records was discontinuity, involving a total of 76 copies （41.3%）; the least distributed defect of medical records was inconformity of medical and nursing records, involving 9 copies （4.89%）. Conclusion Some measures should be taken to reduce defects and improve the quality which are strengthening the legal consciousness and writing knowledge training, strengthening the medical records safety management and supervision system.