采用PDCA循环优化我院病历管理研究

Optimization of Medical Records Management in our Hospital by PDCA Cycle

目的:探讨将PDCA循环应用于病历管理的效果。方法:采用PDCA循环对我院病历管理进行优化,通过对人员、管理、环境三个方面问题进行分析、制定计划、具体实施、实施效果检验、问题反馈等,不断优化我院病历管理。结果:与未使用PDCA循环对我院病历管理相比较显著的降低了出院医嘱缺失和过简率(χ~2=145.576,P=0.000)、诊疗经过缺失和过简率(χ~2=84.348,P=0.000)、症状及体征缺失和过简率(χ~2=61.096,P=0.000)、书写超时率(χ~2=75.851,P=0.000)。结论:将PDCA循环应用于病历管理,可不断的优化病历管理制度,使病历书写标准化。

Objective： To explore the effect of applying PDCA cycle to medical record management. Method： Based on medical records management in our hospital through the optimization of PDCA cycle, personnel, management, environment three aspects analysis, planning, implementation, implementation of specific inspection, performance feedback, continuous optimization of medical records management in our hospital.Results： Compared with the unused PDCA cycle to hospital medical record management,the significant decrease discharge instructions missing and simple （X^2=145.576,P=-O.OOO）,Diagnosis and treatment missing and simple（X^2=84.348,P=-0.000）,Symptoms and signs missing and simple （X^61.096,P=-0.000）,Write timeout （X^2=75.851,P=O.OOO）.Condusiom applying PDCA cycle to medical record management can optimize medical record management system and standardize medical record writing.