PDCA循环法在COVID-19流行病学史专项质量控制中的应用  

Effect of PDCA cycle on special quality control of COVID-19 epidemiological history

作　　者：康娅 张欣欣[1] 许莹 彭蓉[1] KANG Ya;ZHANG Xinxin;XU Ying;PENG Rong(First Affiliated Hospital,Xi’an Jiaotong University,Xi’an 710061,China;不详)

机构地区：[1]西安交通大学第一附属医院,陕西西安710061

出　　处：《现代医院》2021年第2期209-211,共3页Modern Hospitals

基　　金：陕西省重点研发计划项目(2019SF-025)。

摘　　要：目的应用PDCA循环质量控制方法解决某三甲医院在2019新型冠状病毒SARS-CoV-2导致的新型冠状病毒肺炎疫情下运行病历的流行病学史缺陷。方法通过医院电子病历平台系统,收集西安交通大学某附属医院2020年1月26日—2020年2月26日住院680例患者及门诊500例患者流行病学史资料,核对书写的规范性,采用PDCA方法进行校正。结果 680份住院患者流行病学史记录有缺陷病历104份,缺陷率为15.3%,其中缺新型冠状病毒流行病学史80份,占11.8%,非新型冠状病毒收治科室如眼科、耳鼻喉科等缺陷率14.2%,高于新型冠状病毒收治科室如感染科、呼吸科等的缺陷率4.2%,差异有统计学意义,P<0.001。流行病学史书写不规范20份,占2.9%,使用PDCA方法进行质量控制后合格率100%。抽查500份门诊病历,门诊合格率100%,缺陷率0%。结论面对突发新型冠状病毒疫情,PDCA循环质量控制方法可以规范流行病学史书写,确保医疗质量及安全。Objective To solve the epidemiological history defect of medical record by applying PDCA cycle in a general hospital under the pandemic caused by Covid-19.Methods The epidemiological history data including 680 inpatients and 500 outpatients in the First Affiliated Hospital of Xi’an Jiaotong University from 26th January to 26th February, 2020 were collected from the hospital electronic medical record system. PDCA circle was used to revise the nonstandard records.Results Among 680 inpatient records, there were 104 defective epidemiological history records, with a defect rate of 15.3%. There were 80 records missing the epidemiological history of Covid-19, accounting for 11.8%. The defect rate of the departments not designated for Covid-19 such as the departments of ophthalmology and otolaryngology was significantly higher than that of the infections and pneumology departments(14.2% vs. 4.2%, P<0.001). There were 20 nonstandard epidemiological history records, accounting for 2.9%. The qualification rate was 100% after the use of PDCA circle. The outpatient qualification rate was 100% from the randomly-selected 500 records.Conclusion PDCA cycle can regulate the writing of epidemiological history medical records and ensure the quality and safety of medical care.

关 键 词：新型冠状病毒 PDCA 医院病历信息 管理方法 

分 类 号：R197.323.4[医药卫生—卫生事业管理] R197.323.1[医药卫生—公共卫生与预防医学]