摘要
目的探讨精神科病案质量管理中应用PDCA循环法的效果。方法选取2016年12月—2017年11月在医院精神科的4008份病例为对照组,进行常规的病案质量管理;2017年12月—2018年11月在医院精神科的4008份病例为观察组,进行PDCA循环法病案质量管理,比较两组书写病历存在的缺陷情况。结果观察组执行医嘱后未记录、体温单项目不全、记录缺乏连贯性等缺陷的比率低于对照组(P<0.05)。结论精神科病案质量管理中应用PDCA循环法具有较好的效果,可以减少书写病历存在的缺陷。
Objective To explore the effect of PDCA circulation method in quality management of psychiatric medical records.Methods From December 2016 to November 2017,4 008 cases in psychiatric department of our hospital were selected as control group,and routine medical record quality management was carried out.From December 2017 to November 2018,4 008 cases in psychiatric department of our hospital were treated as observation group,and the quality management of medical records by PDCA circulation method was carried out.The defects of medical records between the two groups were compared.Results The rate of unrecorded of doctor's order execution,incomplete body temperature records and incoherent records in the observation group was significantly lower than those in the control group(P<0.05).Conclusion The application of PDCA circulation method in the quality management of psychiatric medical records has a good effect and can significantly reduce the defects in writing medical records.
作者
周晓静
曹晓铮
ZHOU Xiaojing;CAO Xiaozheng(Department of Medical Records,Tianjin Anding Hospital,Tianjin 300222,China)
出处
《继续医学教育》
2019年第9期90-92,共3页
Continuing Medical Education
关键词
精神科
病案室
病案质量管理
PDCA循环法
病历书写
缺陷
psychiatric department
medical record room
medical record quality management
PDCA circulation method
medical record writing
defects
