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目的:通过实施痕迹管理,观察其对病区护理质量及护理安全的影响。方法:病区从2015年度开始对护理质量和护理安全实施痕迹管理,主要是将病区每日每个时间段出现的护理问题记录在“护士长五查房记录本”上、将病区每个月发生的护理问题记录在“护理缺陷讨论登记本”上,使护理质量持续改进有据可依,且不留间隙。随机抽取2015年度实施痕迹管理的病区病例每季度30例,作为观察组,随机抽取2014年度未实施痕迹管理的每季度病例30例作为对照组。分别对两组的病例护理质量进行评价,评价指标是护理文件书写质量得分、危重患者护理质量评价得分、基础护理质量得分、患者对护理的满意度。比较实施痕迹管理前后的护理质量及患者的满意度。结果:观察组的综合护理质量得分及患者的满意度明显高于对照组,两组比较具有显著差异(P<0.05)。结论:通过痕迹管理的实施可有效提高病区护理质量及患者的满意度,对优质护理服务持续开展具有促进作用。
OBJECTIVE: To observe the impact of trail management on the quality of care and safety of wards by implementing trail management. Methods: The Ward started to carry out the trace management on the quality of nursing care and nursing safety from 2015, mainly recording the nursing problems appearing at each time zone in the ward on the “fifth examining record book of nurses” District nursing issues occur every month recorded in the “registration of nursing defects,” so that the quality of care continued to improve evidence-based, and without leaving gaps. Thirty cases were randomly selected from each ward in 2015 for trace management. As the observation group, 30 cases were randomly selected as the control group. The quality of case care was evaluated in two groups. The evaluation indexes were the score of nursing document writing, score of nursing quality evaluation of critically ill patients, score of basic nursing quality, patient satisfaction of nursing. Compare the quality of care before and after the trail management with patient satisfaction. Results: The overall quality of care scores and patient satisfaction were significantly higher in the observation group than in the control group, with significant differences between the two groups (P <0.05). Conclusion: The implementation of trace management can effectively improve the quality of patient care and ward satisfaction, and promote the continuous development of quality nursing services.