個案追蹤法在分級護理質量評價中的應用研究

陳春蘭　廖桂芳　徐明芳　陳銳　石慧

【摘要】 目的：研究個案追蹤法在分級護理質量評價中的應用效果。方法：以危重癥患者為契入點，選取2013年1-12月應用傳統檢查方法的對照組與2016年1-12月應用個案追蹤法的試驗組，每組患者各360例，檢查本院活水院25個臨床護理單元分級護理質量，對住院患者分級護理質量的相關指標進行檢查及數據統計，其中重點對三短九潔執行率、安全標識執行率、風險評估及預防執行率、護理措施執行率、護士病情知曉率、護理記錄合格率、患者滿意度等各項質控指標及各項護理合格情況進行追蹤檢查。結果：兩組分級護理各項質控指標及護理合格情況比較，差異均有統計學意義（P<0.05）。結論：個案追蹤法有利于提高護理管理者在檢查過程中及時發現護理工作中存在問題，同時對問題進行追蹤，促進了分級護理質量持續改進，提升了護理管理水平，保證患者安全。

【關鍵詞】 個案追蹤； 質量評價； 分級護理

Application Study of Case Tracking Method in Grading Nursing Quality Evaluation/CHEN Chunlan，LIAO Guifang，XU Mingfang，et al.//Medical Innovation of China，2017，14（32）：108-111

【Abstract】 Objective：To study the application effect of case tracking method in graded nursing quality evaluation.Method：With critical patients as entry point，the control group with traditional examination method in January to December 2013 and test group with case tracking method from January to December 2016 were selected，360 cases in each group，they were used to assess the quality of nursing care in 25 clinical nursing units in our hospital，to examine the relevant indicators of graded nursing quality of hospitalized patients and data statistics.The execution rate of three short and nine clean，security identifier execution rate，risk assessment and preventive execution rate，implementation rate of nursing measures，nurses awareness rate of illness，qualified rate of nursing records，patient satisfaction of each quality control index and nursing qualification were tracked inspection.Result：The quality control indexes of grading nursing and nursing qualification of two groups were compared，the differences were statistically significant（P<0.05）.Conclusion：Case tracking method is helpful to improve the nursing managers in inspection process in time to find problems in nursing work，and to track the problems at the same time，to promote the continuous improvement of the quality of grading care，to improve the level of nursing management and ensure the safety of patients.

【Key words】 Case tracking； Quality evaluation； Grading nursing

First-authors address：First Peoples Hospital of Jiujiang City，Jiujiang 332000，China

doi：10.3969/j.issn.1674-4985.2017.32.027

追蹤方法學是一種十分科學的護理方法，受到國內外臨床醫學的普遍關注，主要是通過對患者整個診療過程進行密切觀察和充分了解，對醫療機構的發展顯著進行評價[1]。追蹤方法學主要分為系統追蹤法和個案追蹤法，其中個案追蹤法主要是自定某個患者，對其診療過程進行追蹤，評價該例患者的護理過程、護理服務技能及護理方案執行力度等[2]。自優質護理開展以來，為突出臨床護理內涵與護理管理的實效，通過新一輪等級評審過程中的專家組引入過程管理方法學理念，以個案追蹤或系統追蹤的方式進行護理質量評價[3-5]。從患者角度審視護理全過程，對護理質量做出綜合評價。本院自2016年……