PDCA在儿科住院病案质控中的应用  

Application on PDCA Circulation of Quality Control of Medical Records in Pediatrics Department

作　　者：胡祥英[1] 周波[1] 刘红娟 黄娆 王开梅[1] Hu Xiangying;Zhou Bo;Liu Hongjuan;Huang Yao;Wang Kaimei(Department of Pediatric;Haikou Maternity and Infant Health Hospital,Haikou 570102,China)

机构地区：[1]海南省海口市妇幼保健院儿科,海口市570102

出　　处：《中国病案》2018年第11期6-8,共3页Chinese Medical Record

摘　　要：目的探讨通过PDCA的管理模式全面提高儿科住院病历书写质量。方法随机抽取某院2016年6月-2016年12月住院3日以上儿科出院病案300份,分析书写质量,查找原因,开展PDCA循环管理,随机抽取干预后的2017年1月-2017年8月出院病案300份,对PDCA管理前后住院病案主要问题的改善情况和两组病案的甲级率进行比较。结果实施PDCA循环管理后,病历书写字迹潦草、错别字、常规检查不全、病案首页记录错误或漏项、异常化验结果分析不完善、对疾病的诊断与鉴别诊断和处理不规范、未体现教学意识、病历书写描述有遗漏、对重要的治疗调整未具体说明、针对性的化验检查不足等主要问题均减少,P<0.001,差异有统计学意义;病案甲级率由92.00%上升至96.33%,P<0.024,差异有统计学意义。结论PDCA循环是一种科学的质量管理方法,对健全病案质量控制体系,提高病历书写质量有明显的促进作用,病案质量持续改进效果明显。Objective To explore all-round improve the quality of medical records in pediatrics by management mode of PDCA. Methods By analyzing the quality status of three hundred out of the hospital medical record at June to December 2016, we found reasons and carried out PDCA cycle management.Then the discharge medical records of January-August 2017 were randomly selected to compare the improvement of the main problems of the hospitalization medical records before and after PDCA management with the first grade rate of the two groups of medical records. Results After the PDCA cycle management, medical record writing scrawl, wrong character, regular check incomplete, the medical record front pages record wrong or incomplete items, abnormal test results analysis, diagnosis, differential diagnosis and treatment for the disease not standard, not teaching consciousness, medical record writing description there are omissions, treatment of important adjustment did not specify, main problems such as lack of specific laboratory examination were all reduced, P〈0.001, the difference was statistically significant; The class a rate of medical records increased from 92.00% to 96.33%, P〈0.024, the difference was statistically significant. Conclusions The PDCA cycle was a scientific quality management thinking and procedure,it played an important role in improve quality control system,improve the quality of medical records. The constant improvement of medical records quality was obvious.

关 键 词：PDCA循环 儿科 住院病案 质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]