摘要
目的探讨PDCA循环在病案质量管理中应用效果。方法通过分析2012年-2013年(PDCA循环管理前,对照组)100份病案,发现病历书写存在的质量问题。根据对照组分析结果实行PDCA循环管理。随机抽查2014年-2015年(PDCA循环管理后,观察组)100份病历质量。对两组住院病案质量评价指标、病历筛查返修率和甲级病案率进行比较。结果观察组住院病案质量评价表得分(96.37±3.71)明显优于对照组(P<0.05);病历筛查返修率(5.50%)明显低于对照组(P<0.05);观察组甲级病案率明显高于对照组(P<0.05)。结论 PDCA循环管理能够明显优化病案质量管理工作,有效的提高病历书写质量,降低筛查返修率,增加甲级病案率,值得推广。
Objective To probe into the application effect analysis on medical record-quality management of the record room by PDCA cycle management. Methods 100 patient records quality present situation and existing problems were analyzed before the PDCA cycle management (from January 2012 to December 2013, the control group). Medical recordswere managed according to the analysis on the results of the control group. 100 patient records quality were analyzed after the PDCA cycle management(from January 2014 to December 2015, the observation group). Hospital medical records quality evaluation index, the class a medical record rate and screening repair rate before and after the PDCA cycle management were compared. Results Hospital medical records quality evaluation index( 96. 37± 3.71 ), the class a medical record rate( 99. 00% )of the observation group were better than that of the control group (P 〈0. 05). The screening repair rate ( 5.50% ) of the observation group were lower than that of the control group (P 〈0. 05), the difference was statistically significant (P 〈0. 05), grade A medical record of the observation group were lower than that of the control group (P 〈0. 05). Conclusion The application effect analysis on medical record quality management of the record room by PDCA cycle management is affirmative, it can significantly optimize the quality of medical record management, effectively improve the quality of medical record writing and lower screening repair rate, it increases the rate of grade A medical record, it is worthy of promotion.
作者
刘宝玲
杨东
林佩珊
Liu Baolin Yang Don Lin Peishan(Medical Administration Division of Longhua Branch of People's Hospital of Shenzhen, Shenzhen 518109, Guangdong Province, China Department of Oncology, Shenzhen people's hospital, Shenzhen 518020, Guangdong Province, China Medical Records Room of Shenzhen people's hospital, Shenzhen 518202, Guangdong Province, China)
出处
《中国病案》
2016年第12期21-23,共3页
Chinese Medical Record
关键词
PDCA循环管理
病历书写
质量管理
PDCA cycle management
Medical record writing
Quality management