基于入院计划单填写完整率的病案质量持续改进

Hospital admission schedule integrity rate based Medical record continuous quality improvement

目的:探讨基于入院计划单填写完整率的病案质量管理持续改进方案。方法:应用PDCA质量改进方法对病案书写质量进行持续改进,将病历书写质量中需要实现的目标、内容分解为计划阶段、执行阶段、检查阶段和总结处理阶段。通过发现问题,制定目标,培训人员,加强检查力度和质量反馈,在每个循环末总结成绩,发现问题,提出整改措施,并将解决发现的问题作为下一循环工作的目标。结果:PDCA质量改进方法可以明显提高病历书写质量,入院计划单填写完整率显著提高。结论:PDCA的质量改进模式是一个行之有效的管理方法,使医院病案书写质量沿着一条规范化、螺旋式的上升轨道运行发展。

Objectives： To discuss hospital admission schedule integrity rate based medical record continuous quality improvement method. Methods： Applying by PDCA quality improvement method, the objective and content of medical record quality control were divided into 4 processes involves plan, do, check and action. The advantages and disadvantages were summarized when a circle was end and countermeasures and objective of the next circle were designed. Results： PDCA quality improvement method could significantly promote medical record quality and hospital admission schedule integrity rate was significantly increased. Conclusions： PDCA mode is an effective management approach to continuous improving medical record quality.