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目的:对护理病历质控在风险管理中的作用和效果进行分析探讨。方法:选取我院2014年1月至2014年12月收治的1000例住院患者作为实验组,以提高病历护理质量为目的,分析护理病例中出现的问题。另选2013年1月至2013年12月间来我院治病且没有进行护理病历质控管理的患者1000例,将其作为对照组,对两组患者护理病例差错率以及对护理的满意度进行对比。结果:实验组患者病历护理文件规范评分与护理质控评分均优于对照组(P<0.05);实验组患者病历差错率与护理纠纷率显著低于对照组(P<0.05);实验组患者的满意度高于对照组(P<0.05)。结论:护理病历质控在风险管理中的作用与应用效果显著,不仅使护理病历质量得到提升,有效降低护理差错率,避免不必要的医患纠纷,同时,在应用过程中得到广大患者的好评与认同,具有临床应用价值与推广价值。
Objective: To analyze and discuss the role and effect of quality control of nursing records in risk management. Methods: A total of 1000 hospitalized patients admitted from January 2014 to December 2014 in our hospital were selected as experimental group. The purpose of this study was to analyze the problems occurred in nursing cases with the aim of improving the quality of medical records. Another 1000 patients who came to our hospital from January 2013 to December 2013 who did not undergo the quality control of nursing records were used as the control group to evaluate the nursing staff’s error rate and their satisfaction with the nursing comparing. Results: The standard score of medical records and the quality of care control scores of experimental group were better than those of control group (P <0.05). The error rate of medical record and nursing dispute rate of experimental group were significantly lower than that of control group (P <0.05) Satisfaction than the control group (P <0.05). Conclusion: The effect of quality control of nursing records in risk management and its application effect are significant. It not only improves the quality of nursing records, but also reduces the nursing error rate and avoids unnecessary disputes between doctors and patients. At the same time, And identity, with clinical application value and promotion value.