品质管理在护理文件书写中的应用

Application of quality control in nursing document writing

目的探讨品质管理(QC)对护理文件书写质量的影响,以提高护理文件的书写质量。方法成立QC小组,对护理文件书写中存在的问题进行要因分析,同时确立并落实改进措施。随机抽取QC活动前(2014年6月前)及活动后(2015年1月后)的病历200份、护理病历100份、交班报告50份进行回顾性评估,比较QC活动前后的护理文件书写质量。结果实施QC后,护理文件书写(包括体温单、医嘱单、护士交班报告、护理病历)缺陷率低于QC活动前(P<0.05),护理文件书写质量评分由活动前的平均得分90分提高到98分。结论 QC能有效提高护理文件的书写质量,值得临床推广。

Objective To explore the impact of quality control （QC） in nursing document writing,and to enhance the quality of nursing document writing. Methods QC term was established,and the questions in nursing document writing were conducted causal factor analysis,meanwhile the improvement measures were established and practiced.200 running records,100 nursing records and 50 shift reports from before the QC activity （before June 2014） to after Qc activity （af- ter January 2015） were randomly sampling and retrospectively analyzed.The quality of nursing document writing was compared before and after the QC activity. Results After QC activity,defect rate of nursing document writing（including temperature sheet,doctors＇ orders,nursing records and shift reports） was lower than that of the before QC activity （P〈 0.05）.The quality of nursing documents writing score from 90 points before QC activity to 98 points after QC activity. Conclusion QC can effectively improve the quality of nursing documents writing,and is worthy of clinical promotion.