运用品管圈管理工具,提高电子病历书写及时率  

Application of quality control circle management in the improvement of electronic medical record timely writing rate

作　　者：龚伟伟[1] 业海燕[1] 肖雨龙[1] 安乐农[1] 柳剑[1] 周湘江[1] 

机构地区：[1]南京医科大学附属南京医院(南京市第一医院)医务处,南京210006

出　　处：《华西医学》2017年第1期101-106,共6页West China Medical Journal

基　　金：南京医科大学"十二五"第二批教育研究课题(2013-19);江苏现代医院管理研究基金立项课题(JSY-3-2015-042);南京医科大学科技发展基金面上项目(2015NJMU063)

摘　　要：目的观察品管圈工具在提高电子病历书写及时率上的运用效果。方法 2014年6月—2015年1月开展品管圈活动管理电子病历书写及时率,通过确定主题、现状调查、要因分析、制定实施策略等方法提高电子病历书写及时率。结果品管圈干预后,电子病历书写不及时率由干预前的39.6%下降到13.8%,其中手术科室由45.6%降至15.2%,非手术科室由33.6%降至12.4%。目标达标率达到124.04%,其中护理记录、抢救记录的超时率均降至0。圈员在品质管理手法、团队凝聚力、自信心、个人综合能力和解决问题的能力等方面有明显提升。结论电子病历及时性管理有其紧迫性和重要性,应运用好电子病历这把"双刃剑",利用品管圈等管理手段,确保电子病历的及时书写。Objective To observe the effect of quality control circle（QCC） management tools to improve the electronic medical record timely writing rate.Methods Between June 2014 and January 2015,we used QCC to manage electronic medical record timely writing rate.By determining the subjects,investigation of the status quo,factor analysis,and and formulation and implementation of strategies,we tried to improve the electronic medical record timely writing rate.Results After QCC implementation,electronic medical records untimely rate dropped from 39.6% to 13.8%,with surgical departments dropping from 45.6% to 15.2% and non-surgical departments from 33.6% to 12.4%.Target compliance rate reached 124.04%,of which the untimely rate of nursing records and the overtime rate of rescue records were both reduced to 0.Quality management methods,team cohesion,confidence,personal comprehensive ability and problem-solving ability all improved significantly.Conclusions The timeliness of electronic medical records management has its importance and urgency.We should make good use QCC management to ensure timely electronic medical records writing.

关 键 词：电子病历 时限管理 品管圈 

分 类 号：R47[医药卫生—护理学]