350份心血管外科手术护理记录单质量分析与措施

Quality analysis and measures for 350 cardiovascular surgical nursing record sheets

目的提高心血管外科手术护理记录单的书写质量，防范护理纠纷发生。方法随机抽取我科2015年1月至2016年3月的手术护理记录单共350份，按照质量管理标准进行检查，分析存在的质量问题并制定改进措施。结果共查出不合格记录单29份，存在问题41处。结论增强护士法律意识和自我保护意识，实施三级质量控制，可提高手术护理记录单的书写质量。

Objective To improve the writing quality of nursing record sheets for cardiovascular surgery and to prevent the occurrence of nursing disputes, Methods A total of 350 surgical nursing record sheets of our department from January 2015 to March 2016 were randomly selected, and checked according to the quality management standard. The improvement measures were formulated after the analysis of existing problems of quality. Result There were a total of 29 unqualified record sheets with 41 existing problems. Conclusions The law and self-protection consciousness of nurses should be strengthened, and 3-level quality control should be implemented, which is conducive to the improvement of the writing quality of surgical nursing record sheets.