Abstract:

Objective

To summarize the application effect and experience of interventional information a nursing document with 3D quality control theory and PDCA theory.

Methods

Taking 3D quality control theory and PDCA cycle theory as the theoretical framework， a nursing informatization team was established to construct the whole process of informatization for patients undergoing interventional therapy.The evaluation scale of clinical nursing informatization was applied to retrospectively compare the completeness rate of writing， economic cost， nurses' satisfaction and compliance in 2021 without using the nursing informatization documents and in 2022 and 2023 using the nursing informatization documents.

Results

The interventional patient information acquisition mode based on object method ring was constructed.Fifteen types of forms have been constructed， including preoperative handover sheet， sub-disease interventional care record sheet，interventional inventory list， interventional treatment safety verification form， interventional patient information registration form and interventional postoperative handover form； Formed.A new document quality control mode of interventional therapy wa formed.The overall satisfaction dimension score of the system model was 4.44±0.61 points， and the use compliance score was 4.45±0.53 points.The completeness rate of document writing increased from 94.63% before use to 97.66% after use.The average cost of related items such as paper per single case decreased from 2.8 yuan before use to 1.56 yuan.There were statistically significant differences in the completeness rate of nursing documents and the average cost of individual paper before and after use（P＜0.05）.

Conclusion

The electronic nursing documents constructed based on the two major theories can improve the compliance， and satisfaction of medical staff and the completeness electronic document writing，save time and reduce expenses， and can be promoted in peers.

Key words: Three-dimensional quality theory, Dai ming ring, Interventional therapy, Nursing document