Application of continuous quality improvement in the quality control of nursing documentation

Abstract

Objective To explore the application effect of continuous quality improvement in the quality control of nursing documentation , and carry out the whole monitoring of the quality of writing nursing documentation so as to improve the quality of nursing documentation .Methods The groups of quality control of nursing documentation in the departments and the department of nursing were established in order to the effective supervision and guidance of writing nursing documentation in the whole process .One thousand two hundred and fifty-one archived medical records from August 2013 to December 2013 were chosen as the observation group , and 1162 records from September 2012 to January 2013 were chosen as the control group .The incidence of defects was compared between two groups .Results The incidences of defects including the temperature records, doctor’s advice, the admission and discharge evaluation records and nursing records were respectively 4.40%,2.80%,4.16%,13.11%in the observation group, and were 11.53%,9.03%,15.49%,35.80% in the control group, and the differences were statistically significant （χ2 =42.487,42.898,84.873,160.424, respectively;P〈0.01）.Temperature records, doctor’s advice, the admission and discharge evaluation records in each defect rate in the observation group were lower than the control group , the difference was statistically significant （P〈0.01）.Incidence rate of most of the problems in nursing records in observation group were lower than the control group , the incidence of individual problems between the two groups has no statistical significance （ P 〉0.05 ）.Conclusions The groups of quality control of nursing documentation in the departments and the department of nursing play important role in the whole process management of writing nursing documentation so as to improve the quality of nursing documentation . Key words: Nursing management Nursing documentation Continuous quality improvement