部队三甲医院护理文书管理学组的实施与效果评价

Practice and effect evaluation of nursing documents manage-ment group in grade-3 A military hospital

目的：探讨部队三甲医院成立护理文书管理学组对护理文书质量的影响。方法建立护理文书管理学组，对医院护理文书进行质量管理，比较实施前后护理病例质量检查得分情况。结果实施后护理病例质量检查得分显著高于实施前（P＜0．01）。结论成立护理文书管理学组，强化护理文书质量的环节管理与终末质量管理，能够有效提高护理文书质量，避免因护理文书书写引起的法律纠纷。

Objective To explore the influence of nursing documents management group （NDMG ） on nursing document quality in grade‐3 A military hospital . Methods T he NDM G w as established and managed the quality of hospital nurs‐ing documents , pre‐ and post‐NDMG nursing case history quality check‐up scores were compared . Results Post‐NDMG nursing case history quality check‐up score was significantly higher （P〈 0 .01） . Conclusion The establishment of the NDMG and the strengthen of link and final quality management of nursing documents could effectively improve the quality of nursing documents and avoid legal disputes caused by nursing documents.