护理文书质量控制方法与成效
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【摘要】目的探讨护理文书质量控制在护理质量中所起的作用。方法将笔者所在科护士纳入研究，将其在质控前后的专业素养以及质控前后的护理记录质量进行比较。结果(1)行质控后，护士在责任心、专业技能、法律意识各方面的专业素养整体水平明显提高，差异有显著性(P<0.05)。(2)质控后，护理记录在体温单漏项、医嘱单签名不规范、记录的重点不突出、记录的内容不完整各方面的不足均有明显改善，差异有显著性(P<0.05)。结论护理文书质量控制有效的提高了护士的专业素养，并大幅度改善了护理文书的不足，对医院的发展起到一定的促进作用。
【关键词】护理文书；质量控制
Methods and results of nursing records control CHEN Ying-xue.The Peoples Hospital of Shanwei,Shanwei 516600,China
【Abstract】ObjectiveTo investigate whether nursing records control works in nursing quality.MethodsThe nurses in our department were involved,and nursing professionalism and quality of nursing records were compared before and after quality control.Results(1)After quality control,in all directions of nursing professionalism responsibility had improved significantly, such as professional skill and legal consciousness,differences were significant(P<0 ......
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