医院护理文件书写质量管理现状调查

Study on the Present Status of Quality Management of Hospital Nursing Documents Writing

目的:调查医院护理文件书写质量管理现状,分析存在问题,为制定规范的质量管理措施提供依据。方法:根据《四川省医院护理质量管理评价标准(试行)2014年版》中《护理文件书写管理质量评价标准》,查阅某市20所医院归档病历中护理文件书写质量管理的情况。结果:三级综合医院、二级综合医院、中医医院、妇幼保健院平均得分为92.69、87.88、83.34、79.02。结论:医院护理文件书写质量水平不高,应提高各级医院护理文件书写质量管理水平,有效规避医疗风险。

Objective To investigate the current situation of quality management of hospital nursing documents writing and analyze the existing problems, providethe basis for the development of standardized quality management measures. Methods To exam thequalitymanagement of nursing documents writing of archival medical records from 20 hospitals by the quality management evaluation standard of nursing documents writing. Results The average scores of the third - class comprehensive hospitals, the second - class comprehensive hospitals, the traditional Chinese medicine hospital, the maternal and child care service centre were 92.69, 87.88, 83.34 and 79.02, respectively. Conclusions The level of quality management of nursing documents writing is not high, we need to raise thatto ensure hospitals can avoid the medical risk when necessary.