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目的:通过实施以专业护士为主体的癌痛质控体系,提高全院癌痛质量管理水平.方法:依托我院癌痛姑息专业小组,通过回顾文献及细读相关规章制度,制定了《癌痛护理质量评分标准》.在每个病区选拔一名癌痛专业护士,统一培训,负责运用《癌痛护理质量评分标准》对各病区癌痛护理质量进行检查、反馈、评价.结果: 经过两年的实践,癌痛质量管理的病历年总数增加(1 273 us 1 524),病历缺陷率下降(72. 74% us 50. 52% ),组织结构完整率(98. 66% us 99. 87% )、护士评估合格率(87. 51% us 95. 93% )、护理记录合格率(41. 71% us 75. 00% )、护理计划合格率(74. 63% us 86. 29% )、健康教育合格率(47. 21% us 84. 06% )、疼痛筛查率(99. 21% us 99. 93% )、8小时评估完成率(99. 14% us 99. 93% )和出院随访率(77. 30% us 96. 33% )均明显提高,差异有统计学意义(P<0. 05).结论:通过制定《癌痛护理质量评分标准》,以专业护士为主体对各病区进行质量管理取得了良好的效果,是一种值得推广的癌痛护理质量管理方式.“,”To improve the quality of cancer pain management in our hospital by implementing a professional nurse-cen-tered cancer pain quality control system. Methods: Relying on the palliative care team, by reviewing literature and reading rules and regulations, we established the Standard for Cancer Pain Nursing Quality Assessment (the Standard), then selected a professional nurse in each ward and trained unitedly. They were responsible for inspection, feedback, and evaluation of the quality of cancer pain care in each ward. Results: After two years of practice, the total annual number of medical records of quality of care in cancer pain management increased (1 273 us 1 524), the medical record defect rate declined (72. 74% us 50. 52% ), and organizational structure integrity (98. 66% us 99. 87% ), nurse qualification (87. 51% us 95. 93% ), nursing documentation quality (41. 71% us 75. 00% ), nursing plan quality (74. 63% us 86. 29% ), health education quality (47. 21% us 84. 06% ), the pain screening rate (99. 21% us 99. 93% ), the 8-hour evaluation completion rate (99. 14% us 99. 93% ) and the follow up rate (77. 30% us 96. 33% ) significantly improved. And the differences were statistically significant (P<0. 05). Conclusion: By establishing the Standard, professional nur-ses have achieved good results in the quality control of cancer pain management in all wards. It is a cancer pain care management meth-od worth promoting.