摘要
目的探究基于PDCA循环理论的质控管理模式在病案首页质量管理中的应用效果。方法选取三明市第一医院病案科2021年6月至2022年12月采用PDCA循环质量控制法整理的病案首页480例为观察组,同时选取2020年1月至2021年5月未采用PDCA质量控制法整理的病案首页480例为对照组,比较两组的病案首页质量。结果观察组病案首页部分填报项目包括有无过敏药物、血型、临床路径、是否疑难、是否危重、麻醉医生、手术或者操作漏项缺失率均低于对照组,差异有统计学意义(P<0.05);观察组书写不规范均、其他填写不规范率均低于对照组,差异有统计学意义(P<0.05),手术编码准确、疾病编码准确率高于对照组,差异有统计学意义(P<0.05);观察组病案首页管理满意度高于对照组,差异有统计学意义(P<0.05)。结论在病案首页质量控制中应用PDCA循环质量控制理论,可有效降低病案首页的缺陷率,提高病案首页资料完整率及管理满意度,值得临床推广借鉴。
Objective To investigate the application effect of quality control management mode based on PDCA circulation theory in quality management of medical record face sheets.Methods Medical record face sheets organized using the quality control method based on PDCA circulation theory of the Department of Medical Records of SanMing First Hospital from June 2021 to December 2022 were selected as the observation group(n=480),and medical record face sheets which were not organized using the quality control method based on PDCA circulation theory from January 2020 to May 2021 were simultaneously selected as the control group(n=480).The quality of the medical record face sheets in the two groups was compared.Results The missing rates of items on the medical record face sheets of the observation group,including the presence or absence of allergic drugs,blood type,clinical pathway,whether it was difficult,whether it was critical,the anesthesiologist,and the missing of surgery or operation,were all lower than those of the control group,with statistically significant differences(P<0.05).The rates of non-standardized writing and non-standardized filling in the observation group were lower than those in the control group,with statistically significant differences(P<0.05).The accuracy of operation code and disease code in the observation group was higher than that in the control group,with statistically significant difference(P<0.05).The satisfaction with the medical record face sheets management in the observation group was higher than that in the control group,with statistically significant difference(P<0.05).Conclusion The application of PDCA circulation quality control theory in the quality control of medical record face sheets can effectively reduce the defect rate of medical record face sheets and improve the integrity rate of medical record face sheets information and management satisfaction.Therefore,the theory is worthy of clinical promotion and reference.
作者
温婷晔
WEN Tingye(Department of Medical Records,SanMing First Hospital,Fujian,Sanming 365000,China)
出处
《中国医药科学》
2023年第13期156-158,163,共4页
China Medicine And Pharmacy
关键词
病案首页
PDCA循环质量控制法
三级质量控制法
病案缺失
管理满意度
Medical record face sheet
PDCA circulation quality control method
Three-level quality control method
Missing of medical records
Management satisfaction
