护理文书质控新模式的应用效果

Application effect of new model in quality control of nursing documents

目的:探讨护理文书质控新模式的应用效果。方法:从2013年7月开始,我院构建扁平化的、广泛化的质控人员网络,充分运用电子信息系统,建立"实时质控-重点抽查-终末质控"的全程信息化的高效质控新模式,实现护理文书质控各步骤,包括问题提出、反馈、修改、数据分析统计均由质控信息系统来完成。结果:实施新模式后,终末质控问题明显减少,与原来模式的数据比较,差异有统计学意义(P<0.05)。缺项、医护不一致、护理记录跟踪不到位、辨证施护不对症等4个问题得到较好解决。结论:质控新模式运用,能大大节省人力,节约时间,提高质控效率,值得各级医院推广应用。

Objective： To explore the application effect of new model in quality control of nursing documents. Methods： From July 2013,the hospital built a flat and extensive network of quality control personnel. By the full use of electronic information systems,we had established new efficient quality control model of ＂ real- time quality control- extensive checks- final quality control＂ with information during the whole process. Therefore every steps of the quality control of nursing documents,including questions posing,feedback,modification,data analysis and statistics,were completed by the quality control information system. Results： After the implementation of the new model,the terminal quality control problems were significantly reduced. Compared with the data of the original model,the difference was statistically significant（ P〈0. 05）. Four major problems,namely lack of medical care,inconsistent care between doctors and nurses,nursing records were not in place and dialectical nursing was not symptomatic,were properly resolved. Conclusion： The new model of quality control can save manpower and time greatly and improve the efficiency of quality control. It is worthy to be popularized and applied in hospitals at all levels.