摘要
目的探讨护理文书质量评价标准细则的制定方法和实施效果。方法回顾和分析既往护理文书记录缺陷,以护理文书书写规范及其相关的法律法规为指南,结合医院实际情况,针对性地制定护理文书质量检查评价标准细则(包括25条单项否决项目和40条评分细则);用定性定量评价法综合判断护理文书质量。结果 2005～2009年护理病历评分从88.20±7.18提高至97.80±2.15,重点病历护理文书合格率从95.83%提高至100%;优良率从55.56%提高至94.22%;单项否决病历从1.66%降至0。结论护理文书质量检查评价标准细则的制定和应用,可有效提高护理文书的质量。
Objective To explore a method for formulating standard details to evaluate the quality of nursing documents and its imple- mentation measures. Methods By reviewing and analyzing defects of previous nursing documents, and according to related rules and regulations of nursing documentation and current situation of hospital, specific guidelines for quality control of nursing documents were developed, which contained 25 single-veto items and 40 rating items. The quality of nursing documents was evaluated by using qualitative and quantitative evaluation. Results Nursing documents scored 88.20±7.18 to 97.80±2.15 in the year of 2005-2009; the qualified rate of important nursing documents raised from 95.83% to 100%, and the excellent rate from 55.56% to 94.22 %, the single-veto rate dropped from 1.66% to 0. Conclusion Application of standard details for evaluating nursing documentation can promote quality of nursing documents.
关键词
护理文书
书写质量
评价细则
质量标准
质量控制
nursing document
writing quality
evaluation details
quality standards
quality control
