护理电子病历质量控制在心内科护理工作的应用

Application of Nursing Electronic Medical Record Quality Control in Nursing of Cardiology Department

目的探讨护理电子病历质量控制在心内科护理工作的应用,对今后护理质控工作提供参考。方法按照随机数表法选取2019年1月31日-2019年12月31日某院心内科实施三级质控后护理电子病历1000份作为观察组,并选取2017年1月1日-2017年12月31某院未实施电子病历质量控制的1000份作为对照组,比较实施电子病历质量控制前后不良事件发生率和护理缺陷发生率,并比较电子病历质量控制实施前后环节质控结果反馈耗费时间和病历质量评分情况。结果观察组不良事件发生率(6.9%)明显低于对照组(14.9%),差异有统计学意义(χ^(2)=32.949,P=0.000)。观察组环节质控结果反馈耗费时间(2.31±0.33)天明显少于对照组(6.69±0.76)天,病历质量评分(96.59±10.31)分明显高于对照组(82.32±9.65)分,差异有统计学意义(t=167.17、31.96,P=0.000)。结论通过对护理电子病历实施三级质量控制管理,可全面提升心内科质控管理工作效率,增强医护之间的沟通,减少护理缺陷,有全面、高效、及时、互动等优点,使护理电子病历质量得到不断改进和提高。

Objectives This paper discussed the application of nursing electronic medical record quality control in cardiology, and provides the reference for nursing quality control in the future. Methods According to the stochastic indicator selection method on January 31 st, 2019-December 31 st, 2019, a hospital heart after implementing a quality care with electronic medical records of 1000 as the observation group, and on January 1 st, 2017-December 31 st, 2017 a hospital before the implementation of electronic medical record quality control 1000 as control group, compare the difference between before and after the implementation of electronic medical record quality control the incidence of adverse events and the incidence of nursing defects, and compare the electronic medical record quality control before and after the implementation of link quality control results feedback time consuming and medical record quality rating. Results The incidence of adverse events in the observation group(6.9%) was significantly lower than that in the control group(14.9%), with a statistically significant difference(χ^(2)=32.949, P=0.000). The feedback time of quality control results in the observation group(2.31±0.33) was significantly lower than that in the control group(6.69±0.76), and the medical record quality score(96.59±10.31) was significantly higher than that in the control group(82.32±9.65), the difference was statistically significant(T=167.17, 31.96, P=0.000). Conclusions Through the implementation of three-level quality control management on nursing electronic medical records, the efficiency of quality control management in the department of cardiology could be comprehensively improved, the communication between doctors and nurses could be enhanced, the nursing defects could be reduced, and the quality of nursing electronic medical records could be continuously improved and improved.