PDCA循环法在病案质量管理中的价值  

The value of PDCA cycle method in quality management of medical records

作　　者：安兴国 刘松 韩勇[1] 武孟孟[1] 程凯[1] 徐树建[1] 邹伟伟[1] 杨振林[1] AN Xingguo;LIU Song;HAN Yong;WU Mengmeng;CHENG Kai;XU Shujian;ZOU Weiwei;YANG Zhenlin(Department of Thyroid and Breast Surgery,Binzhou Medical University Hospital,Shandong,Binzhou 256603,China)

机构地区：[1]滨州医学院附属医院甲状腺乳腺外科,山东滨州256603

出　　处：《中国医药科学》2021年第1期200-203,213,共5页China Medicine And Pharmacy

摘　　要：目的探讨PDCA循环法在甲状腺乳腺外科病案质量管理中的价值。方法随机抽取2019年1—12月滨州医学院附属医院甲状腺乳腺外科住院病案4065份,作为分析对象。界定2019年1—6月为PDCA循环法实施前时间段,住院病案共计1774份,作为常规病案质控组;界定2019年7—12月为PDCA循环法实施时间段,住院病案共计2291份,作为PDCA病案质控组,统计分析两组病案管理数据及终末病案具体缺陷情况,调查两组病案管理质量评分。结果PDCA组病案3 d出科率(94.11%)、7 d归档率(99.78%)、甲级病案率(99.52%)均明显高于常规组病案3 d出科率(90.53%)、7 d归档率(98.88%)、甲级病案率(98.65%),差异有统计学意义(P<0.05);PDCA组质控问题病案率(8.42%)明显低于常规组质控问题病案率(11.27%),差异有统计学意义(P<0.05)。PDCA组终末问题病案200份共出现223项缺陷,平均1.1项/份,常规组问题病案193份共出现268项缺陷,平均1.4项/份,PDCA组平均缺陷率(1.1项/份)明显低于常规组平均缺陷率(1.4项/份),差异有统计学意义(χ^(2)=4.021,P<0.05);PDCA组病程错误率(12.11%)、会诊单错误率(1.34%)明显低于常规组病程错误率(18.66%)、会诊单错误率(6.72%),差异有统计学意义(P<0.05)。PDCA组病案管理质量总分为(88.95±3.67)分,高于对照组病案管理质量总分的(75.68±4.33)分,差异有统计学意义(P<0.05)。结论PDCA循环法在甲状腺乳腺外科病案质量管理中发挥显著作用,可明显降低病案缺陷率,提升甲状腺乳腺外科病案质量管理,具备应用价值,值得于临床推广使用。Objective To investigate the value of PDCA cycle in quality management of medical records in the department of thyroid and breast surgery.Methods A total of 4065 inpatient medical records in the department of thyroid and breast surgery admitted to Binzhou Medical University Hospital from January to December 2019 were selected as analysis objects randomly.January to June in 2019 was defined as the period before implementation of PDCA cycle method,and a total of 1774 inpatient medical records were adopted as the quality control of conventional medical record group.July to December in 2019 was defined as the period of implementation of PDCA cycle method,and a total of 2291 inpatient medical records were adopted as the quality control of PDCA medical record group.The management data of medical records and the specific defects of the final medical records in both groups were counted and analyzed,and the scores of quality management of medical records in both groups were investigated.Results The three-day turnover rate(94.11%),seven-day archiving rate(99.78%)and class-A medical record rate(99.52%)in the PDCA group were all significantly higher than the three-day turnover rate(90.53%),seven-day archiving rate(98.88%)and class-A medical record rate(98.65%)in the conventional group,and the differences were statistically significant(P<0.05).The rate of quality control problems in medical records in the PDCA group was 8.42%,which was significantly lower than 11.27%in the conventional group,and the difference was statistically significant(P<0.05).There were 223 defects in 200 medical records with final problems in the PDCA group,with an average of 1.1 items each copy.There were 268 defects in 193 medical records with problems in the conventional group,with an average of 1.4 items each copy.The average defect rate in the PDCA group(1.1 items each copy)was significantly lower than that of the conventional group(1.4 items each copy),and the differences were statistically significant(χ^(2)=4.021,P<0.05).The rate of disease cour

关 键 词：PDCA循环法 病案 质量管理 甲状腺乳腺外科 

分 类 号：R197.323[医药卫生—卫生事业管理]