PDCA循环法在纠正护理电子病历缺陷中的应用

Application of PDCA cycle in correcting the defects in nursing electronic medical records

目的探讨PDCA循环法在纠正护理电子病历书写缺陷中的应用效果。方法运用PDCA循环管理方法找出电子护理病历存在的问题,分析原因,提出整改措施,计划实施,并进行评价总结,循环改进。结果使用PDCA循环管理后,电子护理病历记录单出现缺陷问题的比例逐月降低;体温单、医嘱单、一般护理记录单和危重护理记录单中出现缺陷问题的比例降低明显。结论运用PDCA循环管理能明显提高护理病历书写质量。

Objective To investigate the effect of PDCA cycle on correcting the defects ofnursing electronic medical record.Methods To investigate and analyze he defects of nursing electronicmedical records.The countermeasures were carried out and evaluated for further improvement.Results There was a decrease in defect rate of nursing electronic medical records afterimplementation of PDCA cycle,esp)ecially in temperature chart,physician^s order sheet,generalnursing record and nursing record for critical ill patients.Conclusion The application ofPDCA cycle can improve the writing quality of nursing records.