护理书写质量管理系统的构建与应用

Establishment and application of IPAD-assisted nursing documentation quality checking system

目的开发和使用基于信息化的护理书写质量管理系统,提高护理书写质量。方法设计基于信息化的护理书写质量管理系统,采取自查、科查和部查每个月对病区护理书写质量进行检查。结果运行护理书写质量管理系统后,护理书写质量得分显著高于运行前,护理书写质控检查各环节耗时显著少于运行前(P<0.05,P<0.01)。结论应用护理书写质量管理系统进行护理书写质量管理,可提高护理书写的准确率、缩短临床护理书写质控时间,提高护理质控效率。

Objective To develop an IPAD-assisted nursing documentation quality checking system, and to improve the quality of nursing documents. Methods We developed an IPAD-assisted nursing documentation quality checking system and fostered 3 kinds of checking methods（ self checking by unit quality inspectors, division checking by nurse managers, and nursing-department led chec- king） to meticulously scrutinize nursing documents every month. Results After application of the IPAD-assisted nursing documenta tion quality checking system, the scores of nursing documents were significantly enhanced, and the time it took for quality checking processes was significantly shortened （P〈0.05, P〈20.01）. Conclusion Application of the IPAD-assisted nursing documentation quality checking system can improve the correctness of nursing documents, reduce the time of quality checking, and improve the ef ficiency of quality control.