PDCA循环理论在肿瘤内科病案质量持续改进中的应用  

Application of PDCA cycle in continuous quality improvement of oncology medical record quality

作　　者：王志明[1] 王妍[1] 金文[1] 刘天舒[1] 

机构地区：[1]复旦大学附属中山医院肿瘤内科,上海200052

出　　处：《中国当代医药》2013年第28期153-155,共3页China Modern Medicine

摘　　要：目的探讨PDCA循环理论在肿瘤内科病案质量持续改进中的应用及可行性,以促进病案质量改进。方法定期检查分析病案中存在的问题,然后运用PDCA循环理论对不合理病案进行干预并观察效果。结果实施PDCA循环后,本科病案质量持续改进达到预期目标,主任主治查房录、首次病程录和出院小结的不规范或差错率分别下降66.7%、60.0%和75.0%。结论 PDCA循环用于肿瘤内科病案持续质量改进效果显著,可在病案质量管理中推广应用。Objective To investigate the application and feasibility of the PDCA cycle theory in the continuous improvement of oncology medical record quality and to promote medical records. Methods The irrational or incorrect medical records were checked up,analyzed and evaluated regularly,then the medical records were intervened based on the PDCA cycle theory and the results were observed. Results After the application of PDCA,the number and the proportion of the irrational or incorrect medical records in our department decreased significantly,and the continuous improvement of record quality achieved the expectaion.The percents of the irrational or incorrect in records of chief or attending physicians,course record for the first time and discharge abstracts decreased 66.7% ,60.0% and 75.0%. Conclution The application of PDCA cycle significantly improved the oncology medical record quality,and it can be widely used in medical record quality management.

关 键 词：持续质量改进 PDCA循环 病案质量 

分 类 号：R197.323[医药卫生—卫生事业管理]