【摘要】 目的对护理文件书写实施全程质量监控,提高护理文件书写质量。方法各科室成立质量管理小组,对护理文件书写质量进行全程有效监督和指导,将2009年1月至2月与2008年1月至2月归档病历的护理文件书写质量进行比较。结果护理文件书写质量提高,护理文件书写缺陷率下降(P<0.01)。结论科室质量管理小组对护理文件书写的全程管理起到了关键作用,保证了护理文件书写质量。更多还原

【Abstract】 Objective To explore the methods and effect of whole process quality control of nursing documentation and improve the quality of nursing records.Methods The quality management team was set up in each clinical unit to carry out whole process supervision and direction in the quality control of nursing documentation.The quality of nursing documentation was compared before and after the set up of quality management team.Results This practice improved the quality of nursing documentation amd reduced the defect rate(P<0.01).Conclusion The quality management team plays an important role in the whole process quality control of nursing documentation and can ensure the quality of nursing documentation.更多还原