PDCA在病历书写时限质量控制中的应用  

The Application of PDCA Method for Medical Records about Time Limit Quality Management

作　　者：陈世景 赵亮[1] 王金凤[1] 林丽丽[1] 辛娜[1] 

机构地区：[1]首都医科大学附属北京潞河医院,北京市101149

出　　处：《中国病案》2016年第4期11-13,共3页Chinese Medical Record

摘　　要：目的 PDCA循环法在病历书写时限质量控制中的应用。方法分析病历书写时限存在的问题,运用PDCA方法对主要问题进行干预并观察效果。结果实施PDCA一年后,随机抽取2015年1月-2015年10月17 782份运行病历,病历书写时限持续改进达到了预期效果,其中:入院记录未在24小时内完成下降86.73%;首次病程记录未在8小时内完成下降93.77%;上级医师首次查房记录未在48小时内完成下降93.66%;术前讨论记录未在术前72小时完成下降94.63%;出院记录未在24小时内完成下降92.92%。结论 PDCA循环法能有效地促进病历书写时限的质控,更好的地提高病历书写质量。在病历书写时限的质控中,对于未解决的问题,在下一个PDCA循环中加以解决,从而构建病历书写时限质量的持续改进模式,是不断完善病案质检工作的基础。Objective To study the application of PDCA method for the medical records about quality control.Method The incorrect medical records about time limit were analyzed, then the medical records about time limit was intervened based on the PDCA and the results were observed. Results After the application of PDCA for one year,randomly chosen 17782 medical records from January to October 2015. The continuous improvement of the medical records about time limit quality achieved the expectation. Resident admit note is not completed within 24 hours dropped 86.73%. Course record for the first time is not completed within 8 hours dropped 93.77%.The superior doctors ward inspection record for the first time is not completed within 48 hours dropped 93.66%. Preoperative discussion record is not completed within 72 hours dropped 94.63%. Discharge record is not completed within 24 hours dropped 92.92%. Conclusion To get a stage of success through the PDCA method in the research. In order to build continuous improvement in the quality of medical records about time limit and improve its quality inspection work. All these issues can be resolved in the next PDCA cycle.

关 键 词：PDCA 病历书写时限 质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]