摘要
目的:探讨中医医院中医护理文书质量控制方法与效果。方法:收集归档病历、运行病历,对护理文书存在的问题汇总、分析。结果:护理文书存在的问题包括体温单和医嘱单错漏项、入院评估表漏项、护理记录不全等,质控前后比较,差异具有统计学意义(P<0.01)。结论:护理质量控制可有针对性地分析和整改问题,使中医医院护士的临床护理书写能力和护理文书书写质量明显提高。
Objective:To investigate the quality control method and effect of TCM nursing documents in TCM hospitals.Methods:Collecting and archiving medical records,running case history,summarizing and analyzing the problems existing in nursing documents.Results:The problems existed in the nursing documents were as follows:missing item in the temperature list and physician's order sheet,the missing items in the admission evaluation table and the nursing records were not equal.There was a statistical significance before and after the quality control(P<0.01).Conclusion:Through the quality control of nursing,targeted analysis and rectification can improve the quality of clinical nursing writing ability and nursing document writing in Chinese medicine hospital nurses significantly.
作者
董红丽
陈岩
阚飞
Dong Hongli;Chen Yan;Kan Fei(EENT Specialized Hospital of Xinjiang Urumqi City 830001;Traditional Chinese Medicine Hospital of Xinjiang Urumqi City 830000)
出处
《中国社区医师》
2017年第23期165-165,169,共2页
Chinese Community Doctors
关键词
中医
护理文书
质控
持续改进
Chinese medicine
Nursing document
Quality control
Continuous improvement
