护理病历完整性查检工具的设计与应用

The design and application of nursing records completeness checking tool

目的 ：设计和应用护理病历完整性查检工具,以提高护理病历质量和管理实效。方法 ：根据JCI医院评审标准的患者评估及病历质量测量要素以及稽查方法,结合临床工作的实践经验,设计了护理病历完整性查检工具。其查检项目包括护理初始评估和再评估、健康教育评估、护理计划4个一级指标以及24个二级指标;每月由护理病历质控专家抽取每个护理单元5%-10%的运行病历,查检结果采用“是、否、不适用”三个层级进行评判。结果 ：应用护理病历完整性查检工具后,护理病历总体完整率提升了2.77%,与应用前比较差异有统计学意义（P〈0.05）;护理再评估、健康教育评估、护理计划记录完整率分别提高3.59%、2.25%、9.12%,与应用前比较差异均有统计学意义（P〈0.05）。二级指标的约束评估、特殊检查/治疗、护理诊断、诊断相关因素、护理目标达成时间的记录完整率分别提高了15.83%、17.04%、22.25%、16.05%、8.42%,与应用前比较差异均有统计学意义（P〈0.01）。通过对护理病历完整性查检工具使用的评价显示,对一级指标项目内容设计满意度分别为96.0%、92.0%、90.0%、90.0%;对“是、否、不适用”评价方式的认可度为90.0%;认为其能提高护理病历完整性作用的占92.0%;查检单份病历平均耗时缩短了49.4%。结论 ：应用护理病历完整性查检工具进行护理病历完整性稽查,简便高效,能提高护理病历质量,从而提升临床护士整体照护能力。

Objective： To improve the quality of nursing records and management effectiveness through design and application of the nursing records completeness checking tool. Methods： According to JCI accreditation standards for patients＇ assessment and medical records quality measuring elements, combining their clinical work experience, the authors designed the nursing records completeness checking tool. It included four primary indicators, named initial nursing evaluation, re-evaluation, health education assessment, and care plan; and 24 secondary indicators. About 5%-10% of the operating records of each nursing unit were extracted and checked monthly by a quality control specialist. Three level results named ＂yes, no, or not applicable（NA）＂ were used for the evaluation. Results： The nursing records complete rate increased 2.77%（P〈0.05） after using the nursing records completeness checking tool. Nursing reassessment, health education assessment and care plan record completeness increased 3.59%, 2.25% and 9.12%, respectively（P〈0.05）. Record completeness of secondary indicators, including constraint assessments, special examination/treatment, nursing diagnosis, diagnosis-related factors, and the nursing goal achieving time record, increased 15.83%, 17.04%, 22.25%, 16.05%, and 8.42%, respectively（P〈0.01）. The evaluation of nursing records completeness checking tool application showed that the satisfaction on four primary indicators design was 96.0%, 92.0%, 90.0%, and 90.0%. The recognition degree of ＂Yes, No, NA＂ judgment methods was 90.0%; and 92.0% nurses believed that it could improve the completeness of the nursing records. The average checking time for one set of nursing records shortened 49.4% compared with before. Conclusion： Application of nursing records completeness checking tool could effectively improve the quality of nursing records.