环节质量反馈对提高护理电子病历质量的影响

摘要

To study the role of link quality feedback in improving the quality of nursing electronic medical records. Methods:300 copies of medi-cal records from March and June 2012 were archived directly by the department without link quality feedback,while 300 copies of medical records October and December had continuous quality feedback for three months by medical record quality control personnel before archived by the department. Compared the writing quality of the two groups of nursing medical records. Results:The defect rate of electronic medical records without link quality feedback was 58. 33%,while the defect rate of those with link quality feedback was 11. 67%,and the difference was significant (P<0. 05). Conclusion:Nursing elec-tronic medical records with link quality feedback can reduce their defect rate,therefore improve their quality of writing.%目的：探讨环节质量反馈在提高护理电子病历质量中的作用。方法：随机抽取我院2012年3~6月出院归档电子病历300份，进行环节质量反馈；选取2012年10~12月持续质量反馈3个月后归档的300份病历，比较两组护理病历的书写质量。结果：环节质量反馈前电子病历的缺陷率是58.33%，环节质量反馈后病历的缺陷率是11.67%，差异有统计学意义(P<0.05)。结论：对护理电子病历进行环节质量反馈能提高护理病历的书写质量，使记录缺陷减少。