眼科251份护理病案质量缺陷的分析

Analysis on Quality Flaws of 251 Pieces of Nursing Records From Ophthalmology Department

目的 :减少护理病案质量缺陷 ,搞好护理病案管理工作。方法 :抽查 2 5 1份出院护理病案 ,找出个性和共性的问题 ,采取针对性措施。结果 :护理病案质量缺陷与工作责任心不强有关。结论 :对护理病案进行全程质量控制 ,是搞好护理病案管理工作的有效方法。

Objective: to decrease the quality flaws of nursing records, to do well in nursing records management. Method: a total of 251 piece of nursing records which patients had already discharged were reviewed and problems of both particularity and generality existed in the nursing records were searched for. And focus measures had been taken. Results: nursing records quality flaw related to poor responsibility of nursing staffs. Conclusion: it is an effective way of doing well in nursing records management to conduct a whole course quality control on nursing records.