应用三级质控流程优化眼科手术护理记录书写质量

Zhongxiyi Jiehe Huli (Zhong-Yingwen Ban)

连燕彬¹ 

关键词: 电子病历;    护理管理;    质量控制;    护理文书;   

DOI  :  10.11997/nitcwm.201809045

学科分类：护理学

来源: Shanghai Jiao Tong University Press

【 摘 要 】

Abstract：Objective To explore the role of three-level quality control process in optimizing quality of nursing records of patients with the ophthalmologic operation. Methods 〓A quality control team was established and the three-level quality control process was adopted. The quality control team leader conducted the first level of quality control on the medical records of patients in the hospital and discharged from the hospital. The second level of quality control focused on the discharged medical records according to the group of doctors. The third level of quality control emphasized on the dynamic quality of medical records in the general departments and to review the discharge medical records, aiming to find defects and propose effective management countermeasures. To select 150 cases of medical records in January, 2017 as the control group, and to select 150 cases of medical records in March, 2017 as the observation group. The quality of nursing records was assessed and compared between two groups. Results 〓The rates of writing defects in body temperature checklist, medical evaluation checklist and nursing records were significantly reduced in the observation group compared with the control group(P<0.05). Conclusion 〓The three-level quality control process can effectively optimize the writing of nursing records, ensure the integrity of nursing records, improve the quality of nursing medical records, reduce the defect rate and cost.

【 授权许可】

CC BY-NC