探讨PDCA管理提高电子护理病历质量的研究  

作　　者：万艳华[1] 章小庆[1] 徐建梅[1] 张超[1] 

机构地区：[1]南昌大学第二附属医院,江西330006

出　　处：《当代医学》2016年第13期100-101,共2页Contemporary Medicine

摘　　要：目的 探讨PDCA管理提高电子护理病历质量的研究.方法 分析2013年6~9月份科室护理病历中存在的缺陷,分析其中原因,然后按PDCA管理方法制定改进计划,落实实施方案,再次检查电子护理病历,调整方案,以达到持续提高的目的,并比较PDCA管理前后的电子护理病历质量.结果 通过PDCA管理,电子护理病历质量明显提高,缺陷病历数量显著减少（P〈0.05）,一般护理记录单、体温单、医嘱单、特殊护理记录单及健康教育单等护理记录上的缺陷亦有显著的下降（P〈0.05）.结论 PDCA管理能显著提高电子护理病历的质量,可在临床推广应用.Objective To investigate the roles of PDCA management in the improvement of the quality of electric nurse record. Methods The defects in the nurse records from June to September in 2013 were analyzed and harvested. PDCA managements were used to improve these defects. According to the defects, different plans were established, and implement in the nurse staff for 2 months. Then the quality of nurse records were inspect again. Results After PDCA managements, the quality of nurse record were improvement. The defects in general nursing record, temperature chart, physician＇s order sheet, special nursing record and health education record were significantly decreased （P〈0.05）. Conclusion PDCA managements could improve the quality of electric nurse records effectively and could be used in clinic.

关 键 词：PDCA管理 电子护理病历 质量控制 

分 类 号：R47[医药卫生—护理学]