持续改进在护理文书三级质控中的应用(1)
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[摘要] 目的：探讨提高病区护理文书质控的方法，进一步提高护理文书书写质量。方法：采用2009年3月~2010年8月进行三级护理文书质控的归档病历中随机抽取300份作为观察组，2009年3月以前进行传统方法质控的归档病历中随机抽取300份作为对照组，对两组病历的基本要求、体温单、医嘱单、首次护理记录单、护理记录单等5项内容缺陷进行分析比较。结果：观察组缺陷明显少于对照组，差异有统计意义(P<0.05)。结论：护理文书的三级质控，能够有效的提高护理文书的质量，避免因护理文书写引起的法律纠纷，是质量管理在护理文书管理中的具体应用，是对护理文书质量实行持续改进的有效方法。
[关键词] 持续改进；护理文书；三级质控
[中图分类号] R197.323 [文献标识码] A [文章编号] 1673-7210(2011)11(b)-113-02
Application of continuous improvement in the tertiary quality control of nursing document
ZHAO Shufang, ZHAO Feng'e, LI Lang
Department of Hand Surgery, Xinhui Hospital Affiliated to South Medical University, Guangdong Province, Jiangmen 529100, China
[Abstract] Objective: To explore the method to improve the quality control of nursing documents and to enhance the quality of nursing documents writing. Methods: The three-level quality control of nursing documents written from March 2009 to August 2010 were adopted as the study group, the traditional method quality control of nursing documents written before March 2009 were adopted as the control group, 300 documents were randomly selected from each group. The 5 sides of defects of the two groups in basic requirements, temperature chart, medical orders, the first nursing record sheets, nursing record sheets were analyzed and compared. Results: The defects in the study group were less than those in the control group, the differences were significant (P<0.05). Conclusion: The three-level quality control can effectively enhance the quality of nursing documents and avoid legal disputes. It's the specific application in quality management and effective methods of continuous improvement.
[Key words] Continuous improvement; Nursing document; Tertiary quality control
护理文书是指护士在临床护理活动过程中形成的全部文字、符号、图表等资料的总和，是护士在观察、评估、判断患者护理问题，为解决问题而执行医嘱、护嘱或实施护理行为过程的记录，是护理人员为患者实施护理行为的记录，是解决争议过程中的重要举证材料[1]。持续质量改进改变了传统的事后管理的回顾性个案分析方式，而是采用持续的针对具体过程问题的质量评估方法进行质量改进，从而提高质量[2]。《医疗事故处理条例》[3]规定，在发生医疗事故争议时，患者有权复印客观性资料。而体温单、医嘱单、护理记录单客观记载患者病情及检查、治疗结果等情况的资料，属于客观性资料。为了应对《医疗事故处理条例》，分析护理文书中存在的缺陷，提高书写质量，我科护理病历从2009年3月开始实行护理文书三级质控，收到了较好的效果。现报道如下：
1 资料与方法
1.1 一般资料
从我科2009年3月以前归档病历中随机抽取300份作为对照组，2009年3月~2010年8月归档病历中随机抽取300份作为观察组，比较两组病历缺陷情况。 ......
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