摘要
目的:确保护理病历书写质量控制措施(质控)的有效性,以提高护理病历书写质量。方法:制定质控实施原则,对质控措施的实施进行指导,并抽取质控措施实施前后连续1 500份护理病历进行书写缺陷比较。结果:各项主要护理病历缺陷明显减少(P<0.01)。结论:质控措施应在质控的原则平台上固化实施,能更有效地实现护理病历质量的提高。
Objective： To warrant the availability of the quality control （QC） for nursing record writing, to improve the quality of nursing record writing. Methods： To develop the principles and guide the practice of QC. To select 1 500 nursing records and compare the writing defects before and after the practice of QC. Results ：The main defects decreased obviously（P 〈0. 01 ）. Conclusion： QC should be practised according to QC principles, it can improve the quality of nursing record effectively.
出处
《现代临床医学》
2008年第6期464-465,共2页
Journal of Modern Clinical Medicine
关键词
护理病历
书写缺陷
质量控制
实施
原则
medical records
writing defects
quality control
practice
principle
