集束化管理策略对提高终末护理病历质量的效果研究

Effect of Cluster Management Strategy on Improving the Quality of Terminal Nursing Records

目的探讨集束化管理策略,是否可提高终末护理病历书写的质量。方法采用随机数字表法分别抽取2016年和2017年终末护理病历各250份,对启用集束化管理策略前后终末护理病历质量各指标得分及总分、终末护理病历等级份数及质控存在的问题进行统计分析比较。结果与2016年比较,2017年启用集束化管理策略后终末护理病历书写质控总分及病历等级差异有统计学意义(P<0.05);终末护理病历质控存在问题中,体温单中测画频次、医嘱单、评估单、护理交接记录单、健康教育计划实施表及书写规范情况较2016年明显改善,差异有统计学意义(P<0.05)。结论通过采用集束化管理策略,可优化流程,提高终末护理病历书写质量。

Objective To explore the strategy of cluster management,whether to improve the quality of terminal nursing records writing.Methods Two hundred and fifty final nursing records were collected by random digital table in 2016 and 2017 respectively.The scores and total scores of the quality of terminal nursing records,the number of final nursing records and the problems existing in quality control before and after the cluster management strategy were statistically analyzed and compared.Results Compared with 2016,there were significant differences in the total score of quality control and the grade of medical records after the introduction of cluster management strategy in 2017(P<0.05);In the quality control of terminal nursing records,the frequency of measurement,the doctor s order,the assessment sheet,the nursing handover record,the implementation of health education plan and the writing standard in body temperature list were significantly improved,compared with those in 2016,and the difference was statistically significant(P<0.05).Conclusion By adopting cluster management strategy,the process can be optimized and the writing quality of terminal nursing records can be improved.