通过PDCA循环法提高病案首页信息质量的应用实践分析

Improving the Medical Records Information Quality of First Page through the PDCA Circulation Method

目的:应用PDCA循环法提高病案首页信息质量。方法:随机抽取2012年上半年和2013年同期住院患者病案首页各200份,对比两组的病案首页信息质量。结果:2013年组的首页资料完整率和手术、疾病编码准确率明显的高于对照组(P<0.005),手术或操作漏填例数明显少于2013年组(P<0.005)。结论:在医院病案首页信息管理工作中,应用PDCA循环法,可有效提高病案首页信息质量,对促进医院综合管理和持续快速健康发展有着十分积极的作用。

Objective To improve the information quality of medical record by PDCA Circulation Method. Methods Two hundreds copies of medical record first page with the same period were randomly selecting among he hospitalized patients between 2012 and 2013 in order to compare to information quality of first page of the medical records between two groups. Results The integrity rate of first page and accuracy rate of operation ,and disease coding in 2013 group were obviously higher than those in control group（ P 〈 0. 005 ）, and the numbers of surgery or filling operation were significantly less than group（ P 〈 0. 005）in 2013. Conclusion using PDCA Circulation Method in management of first page of medical record could effectively improve the information quality of first page and promote the comprehensive hospital management and health development sustainably.