团队互查方式在某院急诊护理记录完善中的应用

Application of Team Mutual Inspection in Improving Emergency Nursing Records in a Hospital

目的 探讨团队互查方式干预在提高某院急诊护理记录书写质量中的应用价值。方法 随机选取某院2019年1月1日-2019年12月31日急诊病案600份作为干预前组。2020年1月1日开始对某院急诊科护理记录采用团队互查的方式进行干预。随机选取2020年1月1日-2020年12月31日急诊科病案600份作为干预后组,比较2组病案中科室分布情况、护理记录缺陷情况。结果 干预后组病案中,体温单眉栏缺项0.50%、眉栏填写错误0.17%、底栏缺项0.33%、底栏填写错误0.50%、标记错误发生率0.67%;护理记录单中存在涂改0.50%、眉栏缺项0.50%、眉栏填写错误0.33%、病情变化无记录0.00%、缺重要检查检验结果 0.33%、漏签字0.67%、医学术语使用不规范0.67%;医嘱执行单中存在漏填0.00%、签字不及时0.00%、药物用法用量记录不清0.00%,各项缺陷均显著低于干预前组,组间比较P<0.05,差异具有统计学意义。结论 某院急诊护理采用团队互查方式干预,对于降低急诊护理记录中的缺陷具有显著作用,护理记录书写质量更准确。

Objectives To explore the application value of team mutual examination intervention in improving the emergency nursing records of a hospital. Methods This study adopted the method of self-control before and after,randomly selected 600 emergency medical records before the intervention and 600 emergency department medical records after the intervention, and compared the department classification and emergency rescue records in the two groups of medical records. Results Of the 600 cases after the intervention, temperature single eyebrow bar default(0.50%), error in eyebrow bar(0.17%), default in bottom bar(0.33%), error in bottom column(0.50%),incidence of marking error(0.67%);In the nursing record, modification(0.50%), missing eyebrow(0.50%),wrong filling in eyebrow(0.33%), no recorded change of condition(0.00%), lack of important examination results(0.33%), missing signature(0.67%), non-standard use of medical terms(0.67%);There is missing filling(0.00%), signature is not timely(0.00%), unclear usage(0.00%), Both were significantly lower than in the pre-intervention period;Difference was statistical significant(P<0.05). Conclusions The emergency nursing in a hospital adopts the method of team mutual inspection to intervene, which has a significant effect on reducing the defects in emergency nursing records, and the writing quality of nursing records is more accurate.