基于PDCA循环法的病案数字化质量控制  

Digital quality control of medical records based on PDCA circulation method

作　　者：张萍[1] 陈学涛[2] 高飞[1] 廖光平 周来新[3] Zhang ping;Chen Xuetao;Gao fei;Liao Guangping;Zhou Laixin(Department of Information Records Statistics, Xinqiao Hospital, Army Military Medical University Chongqing, 400037 China;Information Department, Xinqiao Hospital, Army Military Medical University Chongqing, 400037 China;Southwest Hospital, Army Military Medical University, Chongqing, 400038 China)

机构地区：[1]陆军军医大学(第三军医大学)新桥医院信息科病案统计室,重庆400037 [2]陆军军医大学(第三军医大学)信息科,重庆400037 [3]陆军军医大学(第三军医大学)西南医院,重庆400038

出　　处：《中华肺部疾病杂志（电子版）》2019年第3期400-402,共3页Chinese Journal of Lung Diseases(Electronic Edition)

基　　金：重庆市社会事业与民生保障科技创新专项(cstc2017shmsA0886)

摘　　要：应用PDCA循环管理提高数字化病案质量。抽取2017年10月-2018年12月新发肿瘤手术和多次手术的病历进行病案数字化质量控制,采用PDCA循环法进行质量持续改进,数据采用excel统计分析。通过PDCA循环法对病案数字化质量控制,2017年10月-2018年12月病案数字化扫描错误发生率不断下降,效果显著。PDCA循环法对病案数字化质量控制是行之有效的管理方法。Objective To improve the quality of digital medical records by using PDCA cycle management. Medical records of new tumors and multiple operations from October 2017 to December 2018 were extracted for quality control. The quality was continuously improved by PDCA cycle method. The data were analyzed by excel. Through PDCA cycle method, the incidence of errors in digital scanning of medical records decreased continuously from October 2017 to December 2018, and the effect was remarkable. PDCA circulation method is an effective management method for quality control of medical record digitization.

关 键 词：病案数字化 PDCA管理 质量控制 

分 类 号：R47[医药卫生—护理学]