380份患者入院护理评估单分析与改进.docVIP

精品论文 参考文献 380份患者入院护理评估单分析与改进 方平（江西省景德镇市第一人民医院护理部 333000） 【中图分类号】R471【文献标识码】B【文章编号】1672-5085（2011）44-0278-02 【摘要】目的 评价患者入院护理评估单，对存在问题认真分析改进，以提高护士正确评估患者、制定切实可行护理措施的能力。方法 在同一时间里从各临床科室随机抽取20份运行病例中的患者入院护理评估单，由经过培训的病历质控护士按照《江西省护理文书书写内容与格式》中护理评估单的书写要求和护理部制定的质控标准进行评价，对存在问题认真分析改进，半年后，再次随机抽取各临床科室20份运行病例中的患者入院护理评估单。结果 经干预后入院护理评估单书写质量显著提高，有统计学意义(plt;0.05)。结论 通过不断的分析评价、学习改进、提高了护士全面准确地评估患者，制定正确护理措施的能力，体现了因人施护，因需施护的优质护理模式。 【关键词】380份入院护理评估单 分析 改进 Analyzing and correcting three hundred and eighty nursing admission assessment records/Fangping//The NO 1 peoples Hospital of Jingdezhen city Jiangxi Province,333000 China 【Abstract]】 Objective: Evaluating the nursing admission assessment record, analyzing and correcting the nursing problems, and improving the nursesrsquo; ability to assess the paitent correctly and devise the feasible nursing measures.Methods: Randomly drawing twenty nursing admission assessment records in runing clinical cases from the clinical departments, evaluating the records by the trained nurses of quality control of paitent history according to the writing requirement of the nursing assessment record in “the Writing Contents and Format of Nursing Record in Jiangxi Province” and the standards of quality control made by the nursing department, analyzing and correcting the nursing problems, and randomly drawing twenty nursing admission assessment records in runing clinical cases from the clinical departments again after half year.Result: Improving the writing quality of the nursing admission assessment record substantially after intervention and having statistical meaning(plt;0.05).Conclusion: By analyzing, evaluating, studying and correcting continuously, improving the nursesrsquo; ability to assess the paitent comprehensively and exactly and devise the correct nursing measures, and embodying the people-oriented and need-oriented high quality nursing mode. 【Keywords】 three hundred and eighty records; the nursing admission assessment record; analyzing; corre