PDCA循环质控管理在门诊病历质量控制中的应用

Application of PDCA Cycle Quality Control Management in Outpatient Medical Record Quality Control

目的探讨基于PDCA循环质控管理在门诊病历质量控制中的应用。方法随机抽取界首市人民医院门诊部2020年1—12月未实施PDCA循环质控管理的门诊病历110例作为对照组,另抽取界首市人民医院门诊部2021年1—12月实施PDCA循环质控管理的门诊病历110例作为研究组。观察PDCA循环质控管理前后病历书写质量、病历书写完整程度以及患者对管理满意度。结果研究组的患者主诉、病史、检查、诊断以及处理评分分别为(16.86±2.54)分、(16.02±2.31)分、(17.25±2.69)分、(17.86±2.94)分、(16.94±2.25)分,均明显高于对照组的(14.82±2.35)分、(13.92±2.14)分、(14.37±2.54)分、(15.61±2.55)分、(14.51±2.17)分(P<0.05)。研究组病历书写完整率为95.45%(105/110),高于对照组的86.36%(95/110)(P=0.019)。研究组患者对PDCA循环质控管理总满意度为96.36%,高于对照组的88.18%(P<0.05)。结论PDCA循环质控管理能够有效提高门诊病例书写质量,提高门诊病历书写完整率以及患者对门诊病历质量的满意度,具有较高的临床意义。

Objective To explore the application of PDCA cycle quality control management in outpatient medical record quality control.Methods A total of 110 outpatient medical records of Jieshou City People's Hospital that had not implemented PDCA cycle quality control management from January to December 2020 were randomly selected as the control group,and another 110 outpatient medical records of Jieshou City People's Hospital that had implemented PDCA cycle quality control management from January to December 2021 were randomly selected as the research group.The medical record writing,medical record quality and patient satisfaction before and after PDCA cycle quality control management were observed.Results The scores of chief complaint,history,examination,diagnosis and management in the study group were(16.86±2.54)points,(16.02±2.31)points,(17.25±2.69)points,(17.86±2.94)points and(16.94±2.25)points,respectively,which were significantly higher of(14.82±2.35)points,(13.92±2.14)points,(14.37±2.54)points,(15.61±2.55)points,(14.51±2.17)points than the control group(P<0.05).The complete writing rate of the study group was 95.45%(105/110),which was significantly higher 86.36%(95/110)of the control group(P=0.019).The total satisfaction of patients with PDCA cycle quality control management was 96.36%in the study group and 88.18%in the control group(P<0.05).Conclusion PDCA cycle quality control management can effectively improve the quality of outpatient case writing,improve the complete rate of outpatient medical record writing and patients'satisfaction with the quality of outpatient medical record,which has high clinical significance.