摘要
目的 采用团队互查方式对急诊重症监护室护理记录单进行管理,以期达到降低书写缺陷,提高护理记录单质量的目的。方法 采用随机抽样方法,选取2021年3月1日-2021年12月31日某院急诊危重症护理记录单200份作为对照组,2022年3月1日-2022年12月31日某院急诊危重症护理记录单200份作为干预组,对照组采取常规管理,干预组采取团队互查方式。对比2组护理记录单质量、书写存在的缺陷。采用计数和卡方检验统计和分析。结果 干预组护理记录单合格率为99.50%,高于对照组95.50%,差异具有统计学意义,P<0.05。干预组护理记录与病情不符的发生率2.00%,医护记录不一致0.00%,护理记录不完整、不连贯0.00%,未使用医学术语1.00%,未体现专科特点1.50%,复制、粘贴记录3.25%,护理措施无效果评价1.00%低于对照组(8.00%、7.00%、5.50%、10.25%、11.75%、14.50%、9.25%),差异具有统计学意义,P<0.05。结论 团队互查方式能提高危重症护理记录单的合格率,降低书写缺陷,促进危重症护理记录持续质量改进。
Objectives In order to reduce the writing defects and improve the quality of the nursing record sheet,the management of the nursing record sheet in the emergency intensive care unit was carried out by peer review method.Methods A random sampling method was used to select 200 critical care records in an emergency department of a hospital from March 1st,2021 to December 31st,2021 as the control group,and 200 critical care records in an emergency department of a hospital from March 1st,2022 to December 31st,2022 as the intervention group.Routine management was adopted in the control group,and team mutual examination was adopted in the intervention group.The quality and writing defects of nursing records were compared between the two groups.Counting and Chi-square test were used for statistics and analysis.Results The single pass rate of nursing records in the intervention group was 99.50%,higher than 95.50%in the control group,and the difference was statistically significant(P<0.05).In the intervention group,the incidence of inconsistent nursing records with medical conditions was 2.00%,medical records were inconsistent 0.00%,nursing records were incomplete and incoherent 0.00%,medical terms were not used 1.00%,specialty characteristics were not reflected 1.50%,and copy and paste records were 3.25%.The effect evaluation of nursing measures was lower at 1.00%than that of control group(8.00%,7.00%,5.50%,10.25%,11.75%,14.50%,9.25%),and the difference was statistically significant(P<0.05).Conclusions Peer review method could improve the qualification rate of critical care records,reduce writing defects,and promote continuous quality improvement of critical care records.
作者
杨淼
李玟羲
李雪晶
崔立霞
左冬晶
Yang Miao;Li Wenxi;Li Xuejing;Cui Lixia;Zuo Dongjing(Department of Emergency,Beijing Chaoyang Hospital Affiliated to Capital Medical University,Beijing 100020,China;不详)
出处
《中国病案》
2024年第6期14-16,共3页
Chinese Medical Record
关键词
团队互查方式
危重症
护理记录单
质量管理
Peer review method
Critical care
Nursing record sheet
Quality management
