PDCA循环在抢救记录专项质量监控中的应用  

Application of PDCA Cycle in Special Quality Control of Rescue Records

作　　者：唐瑶 尹龙燕[1] Tang Yao;Yin Longyan(The First People's Hospital of Guangzhou,Guangzhou 510180,Guangdong Province,China)

机构地区：[1]广州市第一人民医院,广东省广州市510180

出　　处：《中国病案》2020年第7期18-21,共4页Chinese Medical Record

摘　　要：目的分析应用PDCA循环前后抢救记录质量情况,探讨运用PDCA循环对提高抢救记录质量的作用。方法按照《医疗机构病历管理规定》《广东省病历书写规范》及相关抢救病案管理规范要求,对2018年1月1日-2018年12月31日PDCA循环前组、2019年1月1日-2019年12月31日PDCA循环后组各1954份抢救记录进行质控,对比分析抢救记录质量改进情况。结果采用PDCA循环管理模式后,总缺陷率由2018年的72.89%降低至2019年的27.83%,各项具体缺陷数量、缺陷率明显下降,采用χ^2检验,每项均P<0.01,差异亦具有统计学意义,其中缺陷数量前4位:生命体征漏写或无具体数字由981频次,降至412频次,缺陷率由50.2%降至21.08%;病情变化及抢救经过笼统由832频次,降至401频次,缺陷率由42.58%降至20.52%;医护不一致问题2018年721频次,2019年降至408频次,缺陷率由36.9%降至20.88%;抢救知情同意书填写不规范由601频次,降至275频次,缺陷率由30.76%降至14.07%。结论2019年抢救记录在完整性、准确性、一致性、规范性等方面存在的问题较2018年明显减少。将PDCA循环管理方法应用于临床抢救记录专项质量监控中,可明显改善抢救记录书写质量,对提高其质量有积极的作用。Objectives To analyze the quality of rescue records before and after PDCA cycle,and explore the effect of PDCA cycle on improving the quality of rescue records.Methods In accordance with the"Regulations on the Medical Record Management of Medical Institutions","Guangdong Province Medical Record Writing Standards"and the relevant rescue of medical record management regulations,on January 1 st,2018 to December 31 st,2018,before the PDCA circulation group,on January 1 st,2019 to December 31 st,2019,PDCA circulation after the set of all 1954 rescue records for quality control,analysis of rescue record quality improvement.Results After using PDCA cycle management model,the total defect rate from 72.89%in 2018 to 27.83%in 2019,the specific defect number and defect rate significantly decreased,the inspection,each all P<0.01,the difference is statistically significant,the defect number four:the vital signs mistyped or no specific digital frequency of 981,412 frequency defect rate from 50.2%to 21.08%;the frequency of illness change and rescue was reduced from 832 to 401 in,and the defect rate was reduced from 42.58%to 20.52%.In 2018,the frequency of medical inconsistency dropped from 721 to 408,and the defect rate dropped from 36.9%to 20.88%.The frequency of filling in informed consent for rescue was 601,but it was reduced to 275,and the defect rate was reduced from 30.76%to 14.07%.Conclusions The problems in the completeness,accuracy,consistency and standardization of rescue records were significantly reduced.The application of PDCA cycle management method to the special quality control of clinical rescue records could significantly improve the quality of rescue records writing,and had a positive effect on improving the quality of rescue records writing.

关 键 词：PDCA循环 抢救记录 质量 监控 

分 类 号：R197.323[医药卫生—卫生事业管理]