病案回收时开展终末病案初级质控PDCA的效果分析  

Analysis of the Effect of PDCA Cycle on the Primary Quality Control of Terminal Medical Records

作　　者：胡海燕[1] 刘亚孔[1] 

机构地区：[1]三峡大学第一临床医学院,宜昌市443003

出　　处：《中国病案》2017年第10期8-11,共4页Chinese Medical Record

摘　　要：目的探讨PDCA循环在终末病案初级质控中的应用效果。方法运用PDCA循环对终末病案初级质控环节进行干预,对干预措施实施前后的结果进行对照研究。采用χ~2检验对PDCA实施前后的初级质控缺陷率和丙级病案缺陷发生率进行统计学检验。结果终末病案初级质控出的问题以缺少医师签字、出院记录出院时间有误、缺少医嘱单等为主,占到了80%以上。应用PDCA循环后,终末病案初级质控总缺陷率由干预前的6.61%降低到6.19%,差异具有统计学意义(P<0.05);丙级病案发生率由干预前的2.25%降低到0.83%,差异具有统计学意义(P<0.001)。结论 PDCA循环用于终末病案初级质控,能够明显地优化病案质量管理流程,值得进一步推广。Objective To investigate the application effect of PDCA cycle on the primary quality control of terminal medical records. Methods PDCA cycle was applied to intervene on the quality control of terminal medical records. Meanwhile, the results were compared before and after the intervention. x^2 test was performed to analysis the defect rate of pre and after PDCA. Results The major defect includes lack of doctor＇s signature, incorrect discharge time on the discharge summary and lack of physician＇s order sheet, with the proportion of more than 80%.Significant difference was observed after PDCA cycle was performed, with the total defect rate dropped from 6.61% to 6.19% and the class C rate from 2.25% to 0.83%. Conclusion The application of PDCA cycle, which was conducted on primary quality control of terminal medical records, can obviously optimize the quality management process and is worth of further promotion.

关 键 词：病案质量管理 PDCA EXCEL函数 

分 类 号：R197.323[医药卫生—卫生事业管理]