质量评价指标管理对提高骨科护理记录单质量的效果观察

The Effect of Quality Evaluation Index Management on Improving the Quality of Orthopedic Nursing Records

目的通过观察应用质量评价指标管理提高骨科护理记录单质量的效果,为提升护理记录单质量和护理人员专业知识提供参考依据。方法某院于2022年5月1日开始对护理记录实施质量评价指标管理,按照随机数表法,选取2021年9月1日-2022年4月30日收治的80例骨科患者作为对照组,选取2022年6月1日-2023年1月31日收治的80例骨科患者作为观察组,对照组采用常规护理记录书写管理方法,观察组实施质量评价指标管理措施,统计实施前后两组护理缺陷发生率,并比较护士对管理措施的满意程度。结果质量评价指标管理实施后护士专科知识掌握(95.09±6.08)分、护理记录书写考核(94.48±7.43)均高于实施前(88.19±5.21、85.11±5.15)分,差异有统计学意义(t=2.725、3.278,P<0.05)。观察组书写错误、眉栏记录错误、药品记录错误、病情记录错误、记录不及时和签名错误等护理记录缺陷发生率(8.97%)明显低于对照组(28.21%),差异有统计学意义(χ^(2)=9.530,P=0.002),实施后护士对书写规范、书写速度和病历书写难度满意度评分明显高于实施前,差异有统计学意义(t=8.506、5.811、8.278,P<0.001)。结论质量评价指标管理可明显提高骨科护理记录单书写质量,提高护理人员专科知识掌握程度,减少护理缺陷发生率,患者满意度较高,值得进一步推广使用。

Objectives This study aims to improve the quality of orthopedic nursing records by observing and applying quality evaluation index management,so as to provide a reference for improving the quality of nursing records and the professional knowledge of nursing staff.Methods A department began to implement quality evaluation index management measures for nursing records on May 1,2022.Random number table method was applied.A total of 80 orthopedic patients admitted from September 1,2021 to April 30,2022 were selected as the control group,and a total of 80 orthopedic patients admitted from June 1,2022 to January 31,2023 were selected as the observation group.The control group adopted routine nursing record writing management methods,and the observation group implemented quality evaluation index management measures.Statistics were made on the incidence of nursing defects in the two groups before and after the implementation,and the nurses'satisfaction with the management measures were compared.Results After the implementation of quality evaluation index management,the scores of nurses'professional knowledge mastery(95.09±6.08)and nursing record writing assessment(94.48±7.43)were higher than those before the implementation(88.19±5.21,85.11±5.15).The differences were statistically significant(t=2.725,3.278,P<0.05).The incidence of nursing record defects such as writing errors,eyebrow record errors,drug record errors,disease record errors,untimely records,and signature errors in the observation group(8.97%)was significantly lower than that in the control group(28.21%),and the difference was statistically significant(χ^(2)=9.530,P=0.002).After implementation,nurses'satisfaction scores on writing standard,writing speed and medical record writing difficulty were significantly higher than those before implementation,and the differences were statistically significant(t=8.506,5.811,8.278,P<0.001).Conclusions Quality evaluation index management can significantly improve the quality of orthopedic nursing record writing,improve the mastery of nursing staff's specialized knowledge,and reduce the incidence of nursing defects.Patient satisfaction is high.This implementation is worthy of further promotion.