The nursing documentation writing analysis of the quality and intervention countermeasures

Objective To investigate the quality of nursing documentation writing status and solutions. Methods Selected 150 medical records in the hospital of Wenzhou Pingyang Yongxin Branch from January 2011 to January 2012as the control group, and to select 150 medical records of the General Hospital over the same period as the study group. And the control group was given the traditional nursing documentation writing terminally quality checking method, and the observation group was given the improved writing quality of nursing documentation writing files with the terminal. The quality of writing quality score of nursing documentation, patients ' satisfaction, incidence of adverse events, body temperature single prescription orders, nursing records check a result of the two groups of patients were compared. Results ①There was a statistical difference of the file writing quality scores, patients ' satisfaction and the incidence of adverse events between the two groups(P 0.05, P 0.01). ②Temperature unilateral: Two layout altered,the project completed, according to the specified measurement inaccurate recording of vital signs and other aspects of a significant difference(P 0.05, P 0.01); ③ Exparte orders: two layout altered, the project completed, according to the specified measurement inaccurate recording of vital signs and other aspects of a significant difference(P 0.05, P 0.01); ④Care record unilateral: both groups in the layout altered, recording was not enough time, health care does not match the description of the situation, the medical term is not used, the condition did not reflect the dynamic changes,and perform recording time when orders are inconsistent with nursing and other differences were statistically signifi cant(P 0.05, P 0.01). Conclusion The improved nursing documentation method of writing is used in nursing doc-umentation writing quality control, can significantly improve the quality of care, patient satisfaction, and it is worthy of promotion and application.