PDCA循环在心内科电子护理病历质量控制中的应用  

Application of PDCA cycle in quality control of electronic nursing records in department of cardiology

作　　者：沈美玲[1] 谢小朋 李建云[1] 陈子杰 赵振华[1] Shen Meiling;Xie Xiaopeng;Li Jianyun;Chen Zijie;Zhao Zhenhua(Department of Cardiology,Guangdong Second Provincial General Hospital,Guangzhou 510310,China)

机构地区：[1]广东省第二人民医院心内一科,广州510310

出　　处：《国际医药卫生导报》2020年第7期1031-1033,共3页International Medicine and Health Guidance News

摘　　要：目的:探讨PDCA循环在心内科电子护理病历质量控制中的应用。方法:2019年5月1日开始将PDCA循环应用于本院电子护理病历的质量控制当中,选取2019年3—4月已被病案室归档的158例且未实施PDCA循环前的病历为对照组,2019年5—6月已被本院病案室归档的172例、实施PDCA循环后的病历为观察组,比较两组病历的质量控制效果,对比护理质量。结果:实施PDCA循环质量控制护理病历后,观察组的电子护理病历总缺陷率为6.40%,而实施前的对照组总缺陷率为22.15%,观察组的病历缺陷率明显低于对照组,两组比较差异有统计学意义(P<0.05﹚。结论:在心血管内科的电子护理病历管理中实施PDCA循环,可以提高护士书写电子病历的能力,提高病历书写合格率,减少医疗纠纷隐患,可在临床上进一步推广。Objective To explore the application of PDCA cycle in quality control of electronic nursing records in department of cardiology.Methods PDCA cycle was applied in quality control of electronic nursing records of our hospital since 1st May,2019.158 medical records which had been filed in record room before implementation of PDCA cycle between March 2019 and April 2019 were selected as the control group,172 medical records which had been filed in record room after implementation of PDCA cycle between May 2019 and June 2019 were selected as the observation group.The quality control effects of the medical records of the two groups were compared,and the quality of nursing were compared.Results After the implementation of PDCA cycle quality control,the rate of defects of electronic nursing records in the observation group was 6.40%,and that in the control group was 22.15%,the rate of medical records defects in the observation group was significantly lower than that in the control group,with statistically significant difference(P<0.05).Conclusion The implementation of PDCA cycle in the management of electronic nursing medical records in department of cardiology can improve the ability of nurses to write electronic medical records,improve the qualified rate of medical records,reduce the medical disputes,which can be further promoted in clinical practice.

关 键 词：PDCA循环 电子护理病历 质量控制 

分 类 号：R473[医药卫生—护理学]