关键词: 最小数据集；护理质量；质量评价；信息化

Abstract: Objective: To construct the minimum data set of quality control in the key links of nursing, with a view to the application of quality control effects in the process of nursing quality control informatization. Methods: By consulting literature and national standards, expert correspondence and based on the third normal form theory of database, the minimum data set of quality control in key links of nursing was developed and applied to the practice of nursing quality control informatization. The changes of nursing quality control time and nursing quality indexes before and after application were compared. Results: The minimum data set of quality control for key links of nursing included 38 items in 6 categories, namely 2 items of personnel management, 2 items of medication management, 12 items of clinical nursing and safety management, 9 items of nursing document management, 8 items of health education management and 5 items of quality management data. After application, the cumulative time of quality control information input, feedback and statistics was significantly shortened (P<0.001), the effective rate of patient identification, the qualified rate of nursing document writing, the qualified rate of overall nursing of responsibility system, the awareness rate of patient health education, and the follow-up rate of discharged patients have increased (P<0.05), and the incidence of falls in hospitalized patients decreased significantly (P<0.05). Conclusion: The application of the minimum data set of quality control in the key links of nursing effectively promoted the informatization, standard processing and rapid feedback of quality control data, and improved the evaluation efficiency of nursing quality control and clinical nursing quality.

Key words: minimum data set; nursing quality; quality evaluation; informatization