PDCA在运行病历书写时限管理的应用

Application of PDCA in Running Medical Record Writing Time Limit Management

目的通过对某三甲综合医院超时限运行病历进行检查,评估PDCA循环在提高运行病历书写时限管理方面的应用效果,促进病历管理。方法从广东省某大型三甲医院电子病历管理系统提取2017年1月1日-2021年6月30日期间出院病案,共计565986份进行病历书写完成时限核查。某院于2017年12月以提高住院病历及时书写为目标开展PDCA循环,以此为界限分为两组,2017年1月1日-2017年12月31日为实施PDCA循环管理前,住院病历126865份作为对照组;2018年1月1日-2021年6月30日期间出院病案439121份作为实施后观察组。实施前后分别对医务人员进行病历书写考核,两组病历书写完成时限进行核查,使用卡方检验比较两组的病历书写质量和运行病历书写超时情况。结果医务人员的培训考核平均成绩从74.83分提升至86.10分,80分以上的住院医师占比从28.96%提升到82.02%;运行病历超时份数显著下降,入院记录、首次病程记录、手术记录、术后首次病程记录同比下降96.47%、89.3%、97.55%和88.35%,从2017年第一季度的1423份下降到2021年第二季度的60份,不合格占比从4.37%下降至0.42%,差异有统计学意义。结论计划-执行-检查-反馈循环管理,有利于提高医务人员运行病历书写的及时性,具有病案质控管理的应用价值。

Objectives This study aims to evaluate the application effect of Plan-Do-Check-Act cycle in improving the management of writing time limits of operating medical records by inspecting the overtime medical records of a tertiary general hospital,so as to facilitate medical record management.Methods A total of 565,986 medical records were extracted from the electronic medical record management system of a large tertiary hospital in Guangdong Province from January 1,2017 to June 30,2021.The time limit for completion of medical record writing was checked.A hospital launched a PDCA cycle in December 2017 with the goal of improving the timely writing of inpatient medical records and the patients were divided into two groups based on this.Chi-square test was used to analyze the differences in medical records writing before the implementation of cycle management(from January 1,2017,to December 31,2017)and after the implementation of cycle management(from January 1,2018,to June 30,2021).Results The average training and assessment score of medical staff increased from 74.83 points to 86.10 points,and the proportion of residents with scores of 80 or above increased from 28.96%to 82.02%.The number of timeout copies of running medical records dropped significantly.Admission records,first course records,operation records,and first postoperative course records decreased by 96.47%,89.30%,97.55%,and 88.35%year-on-year.It dropped from 1,423 in the first quarter of 2017 to 60 in the second quarter of 2021,and the proportion of unqualified applicants dropped from 4.37%to 0.42%.The difference was statistically significant.Conclusions The Plan-Do-Check-Act management is beneficial to improve the timeliness of medical staff in writing and running medical records and has the application value of strengthening the quality control management of medical records.