基層醫(yī)院危重病人護理記錄存在問題的分析和對策

【摘要】目的:通過對我院危重病人護理記錄單的回顧性調(diào)查，分析存在的問題，提出針對性的整改措施，以提高護理質(zhì)量。方法:整改前抽查危重病人護理病例600份，針對其存在的問題加強質(zhì)控管理，整改后抽查612份危重病人護理病例，對兩組病例存在的問題進行比較，并進行統(tǒng)計學(xué)分析。結(jié)果:兩組比較差異有顯著性，整改后護理記錄質(zhì)量明顯提高(P<0.05)，結(jié)論:有針對性的，多元化的管理是提高危重病人護理記錄質(zhì)量的保障。

【關(guān)鍵詞】基層醫(yī)院;危重病人護理記錄;護理管理

【中圖分類號】R197.323【文獻標(biāo)識碼】A【文章編號】1007-8517(2010)12-019-2

Analysis and strategy of existing problem on nursing record of critical patient in primary hospital

Liu guihualiu guiying

The second people’s hospital of Pixian，Sichuan Chengdu 611733，China

[Abstract] objective:To analyze existing problem，propose rectification measures and improve the quality of care by retrospectively investigating to nursing record of critical patient in my hospital. Method:To draw randomly 600 cases of critical patient before rectification measures was Implemented and 612 cases of critical patient after rectification measures was Implemented，and observe and analyze statistically difference of two groups. Result:Difference of two groups is significant. nursing record is improve notablely. Conclusion:Aimed，diversified management is important to improve the quality of nursing record on critical patient.

[Key words] primary hospital;nursing record of critical patient;nursing supervision