品管圈在提高住院病案首页项目填写完整率中的应用效果

Application of Quality Control Circle to improve the Completion Rate of Items on the Front Page of Inpatient Medical Records

目的评价品管圈在提高住院病案首页项目填写完整率中的应用效果,为制定改善策略提供依据。方法选取品管圈活动前2020年1月1日-2020年6月30日8499份住院病案首页作为实施前组,品管圈活动后2020年7月1日-2020年9月30日6577份住院病案首页作为实施后组,对2组住院病案首页填写完整率进行质控,改善前后住院病案首页项目完整率比较。在活动前后全体圈员均填写自我评定表,比较活动后各项目得分及活动成长值。结果品管圈活动后住院病案首页项目填写完整率实施前组为86.53%;实施后组为95.75%,组间完整率经χ^(2)检验,P<0.05,差异有统计学意义,目标达标率103.02%,进步率10.66%。手术和操作信息完整率由36.62%提高至80.89%,χ^(2)=2948.338,P<0.05;出院诊断和其他诊断的完整率由45.28%提高至82.68,χ^(2)=2193.113,P<0.05,差异具有统计学意义。圈员自我评定的活动成长值达到9.56。结论品管圈管理工具可有效提高住院病案首页项目填写完整率,促进住院病案首页填写质量持续提高,充分发挥品管圈的优势,促进病案管理水平提高。

Objectives To evaluate the application effect of Quality Control Circle in improving the completion rate of items on the front page of inpatient medical records,and provide a basis for the formulation of improvement strategies.Methods A QCC was set up,PDCA cycle and other methods were used,aiming to improving the completion rate of the information on the front page of inpatient medical records.Plato method was used to evaluate the effect.8,499 front pages of inpatient medical records from January 1st,2020 to June 30th,2020 before the launch of QCC activities and 6,577 front pages of inpatient medical records from July 1st,2020 to September 30th,2020 after the launch of QCC activities were selected for statistical analysis.Results After the QCC activities and other interventions,the completion rate of the front page was gradually increased,from 86.53%in June 2020 to 88.78%in July,and 95.75%in September.The difference was statistically significant(P<0.001)according to the Chi-square test.The target standard reaching rate was 103.02%,and the progress rate was 10.66%.The completeness rate of operation and operation information increased from 36.62%to 80.89%(χ^(2)=2948.338,P<0.001),the completeness rate of discharge diagnosis and other diagnosis increased from 45.28%to 82.68(χ^(2)=2193.113,P<0.001).The integrity rate of contact address increased from 49.30%to 91.36%(χ^(2)=2997.72,P<0.001),and the integrity rate of place of birth and native place increased from 66.63%to 96.14%(χ^(2)=1981.025,P<0.001).Conclusions QCC management tool could significantly improve the completion rate and the quality of the information on the front page of inpatients medical records.Give full play to the advantages of quality control circle,we could promote the improvement of medical record management level.