摘要
目的研究分析应用PDCA循环改进运行病历质控的效果。方法随机抽选2021年1—2月医院76份运行病历作为对照组(实施常规管理),随机抽选2021年11—12月医院76份运行病历作为研究组(实施PDCA循环改进管理)。对比两组运行病历病程记录书写和手术相关记录及时、规范情况。结果研究组入院记录、首次病程记录、首次上级医师查房记录、三级医师查房记录、知情同意书签署、术前小结及术前讨论结论记录、手术安全核查记录、手术记录、术后首次病程记录、术后3 d病程记录、会诊记录及危急值记录及时、规范性均比对照组高,差异有统计学意义(P<0.05)。结论在病历质控管理中实施PDCA循环改进,可提高病历管理控制质量,使病历书写更加及时、规范和完整。
Objective To study and analyze the effect of applying PDCA cycle to improve the quality control of operating medical records.Methods 76 operating medical records in the hospital from January to February 2021 were randomly selected as the control group(implemented routine management),and 76 operating medical records in the hospital from November to December 2021 were randomly selected as the study group(implemented the PDCA cycle improvement methodmanagement).The time and standardization of the writing of medical records and operation-related records in the two groups were compared.Results Admission records,records of the first course of the disease,records of the first rounds of the superior physician,records of the rounds of the third-level physicians,signing of informed consent,records of preoperative summaries and preoperative discussion conclusions,records of surgical safety verification,records of surgical safety,records of the first course of surgery after surgery,records of the course of the three days after surgery,records of consultations and records of critical value were timely and standardized in the study group were higher than those in the control group,the difference was statistically significant(P<0.05).Conclusion Implementing PDCA cycle improvement in medical record quality control management can improve the quality of medical record management and control,and make medical record writing more timely,standardized and complete.
作者
李明霞
LI Mingxia(Quality Control Department,Jinan Third People's Hospital,Jinan,Shandong Province,250132 China)
出处
《中国卫生产业》
2022年第8期153-156,共4页
China Health Industry
关键词
病历
管理
书写质量
PDCA循环
质量管理
Medical records
Management
Writing quality
PDCA cycle
Quality management
