摘要
目的探讨PDSA质量管理工具在推进医院病案质控审核系统建设中的作用,以及持续提升病案首页数据智能化审核质量的路径。方法以真因验证方法分析病案质量管理现状,遵循PDSA质量管理理论和程序,采取计划、执行、研究评估和处理等流程,开展专项试点、成效验证和循环改进措施,推动病案质控智能化审核全流程提升。结果实施PDSA循环管理措施后,入院记录24小时内完成率、手术记录24小时内完成率、出院记录24小时内完成率、病案首页24小时内完成率均达到预设目标值,医生首页主要诊断选择正确率大幅提高,病案质控智能化形成规范化、可视化工作机制。结论应用PDSA循环管理能有效改善和提升病案首页数据智能化审核质量,推动构建科学的病案质控智能化审核工作体系。
Objective To explore the role of PDSA quality management tool in promoting the construction of hospital medical record quality control audit system,and the path to continuously improve the quality of intelligent audit of medical record first page data.Methods Analyzing the current state of medical record quality management using root cause verification methods,we followed the PDSA quality management theory and process,implementing planning,execution,evaluation,and handling procedures.Special pilot programs,effectiveness validation,and iterative improvement measures were undertaken to enhance the entire process of intelligent medical record quality control review.Results After implementing PDSA cycle management measures,the completion rates for admission records,surgical records,discharge records,and medical record cover pages within 24 hours all reached the preset target values.The accuracy of the main diagnosis selection by physicians significantly improved,resulting in a standardized and visualized work mechanism for intelligent medical record quality control.Conclusion The application of PDSA cycle management can effectively improve and enhance the quality of intelligent review of medical record cover pages,facilitating the construction of a scientific system for intelligent medical record quality control review.
作者
汤洁芬
胡秀葵
何伟媛
何春霖
TANG Jiefen;HU Xiukui;HE Weiyuan;HE Chunlin(Zhongshan People′s Hospital,Zhongshan 528400,China)
出处
《现代医院》
2024年第10期1527-1530,1534,共5页
Modern Hospitals
基金
中山市社会公益与基础研究项目基金(2022B1036)。
