摘要
目的 调查和分析影响护理文件书写质量的相关因素 ,探讨护理文件书写品质改进策略。方法 采用回顾性调查方法 ,对 6所医院 2 0 0 2年 9月至 2 0 0 3年 9月的内科、外科、儿科共 12 0 0份出院护理病史进行调查、统计和分析 ;采用问卷调查法和现场调查法 ,对各层次护理人员调查目前护理病史书写质量问题的症结及对策。结果 12 0 0份护理病史书写普遍存在 :主观描述较多、形式格式繁冗、患者的动态变化不能完全体现等问题。这与护理管理机制、人员结构层次、法律意识等因素有关。结论 ( 1)简化护理文件书写格式 ,发展专科表格式护理记录 ,医疗护理记录合并书写 ,发展数字化护理病历 ;( 2 )加强质量监控 ;( 3 )加强护理人员法律意识 ;( 4 )
Objective To investigate and analyze related factors affecting the quality of nursing documentation, and discuss improvement methods.Methods 1) We reviewed and analyzed retrospectively 1,200 outpatient nursing documents from departments of medicine, surgery, pediatrics, gynecology and obstetrics of 6 hospitals between Sept.2002 and Sept.2003; 2) Different levels of nursing staff were investigated by on-the-spot questionnaire.Results Problems commonly existing in nursing document writing included too much subjective description, redundant stereotype and incomplete recording of patients’ dynamic changes. These problems were related to such factors as the nursing management system, stratification of nursing staff and legal awareness.Conclusion It is suggested that 1) the format of nursing documentation should be simplified by developing specialized form styles for nursing records, combining medical record with nursing record, and developing digital nursing case histories; 2) quality control should be strengthened; 3) legal awareness should be enhanced among nursing staff , and 4) the nursing management system should be reformed.
出处
《解放军护理杂志》
2004年第8期26-27,共2页
Nursing Journal of Chinese People's Liberation Army
关键词
护理文件
书写质量
分析
品质改进
nursing documentation
quality control
nursing management
