应用品管圈提高病案资料完整率的效果观察  

Effect of quality control circle on complete rate of medical records

作　　者：李清香 陈海燕 朱兴爱 刘琳 莫新颖 邓玉萍 LI Qingxiang;CHEN Haiyan;ZHU Xing’ai;LIU Lin;MO Xinying;DENG Yuping(The Second People’s Hospital of Qingyuan City,Qingyuan 511800,China;不详)

机构地区：[1]清远市清新区人民医院,广东清远511800

出　　处：《现代医院》2021年第6期919-921,共3页Modern Hospitals

摘　　要：目的观察应用品管圈对病案资料完整率的影响。方法成立品管圈活动小组,按照品管圈活动的十大步骤实施。首先由圈成员对2019年5月10日-17日的出院病案843份的完整性进行查检与分析,确定目标值后,根据存在问题查找要因,确定真因,制定实施方案进行改善,并对2019年11月1日-9日出院病案826份的完整性进行查检。评价实施品管圈活动后的有形成果:病案资料完整率,进步率、目标达标率和无形成果。结果通过对现状调查的不完整病案资料分析,发现漏单、漏页较多的科室依次为普通外科与神经内科,而漏单、漏页最多的项目则分别为影像学报告与检验报告。现状调查得出病案资料不完整份数为96份,病案资料完整率为88.61%,而实施品管圈活动后病案资料不完整份数为15份,病案资料完整率为98.18%,差异有统计学意义(P<0.05),进步率为10.80%,目标达标率为101.96%。结论在病案资料管理中,采取品管圈管理模式,可以对病案资料不完整因素进行有效的分析,并在实施品管圈管理后,病案资料的完整性有着较为明显的改善效果,圈员们活动信心、沟通能力以及QCC手法运用能力、团队凝聚力以及个人的能力也得到明显的提升。Objective To observe the application effect of quality control circle on the complete rate of medical records.Methods SA quality control circle activity team was set up and implemented in accordance with the ten major steps of quality control circle.First,the circle members checked and analyzed the completeness of the 843 medical records discharged from our hospital during May 10,2019 to May 17,2019.After determining the target value,the main causes based on the existing problem were analyzed to find out the true cause.Then a plan for improvement was worked out and then the completeness of 826 medical records from the hospital during November 1,2019 to November 9,2019 was checked.The tangible results after the implementation of quality control circle activities including the intangible results and the tangible such as the complete rate of medical records,progress rate,targeted achievement rate.Results Through the analysis of the incomplete medical record data,it was found that the departments with the most missed pages were the departments of general surgery and neurology,and the items with the most missed pages were the imaging report and the inspection report.According to the investigation,there were 96 cases of incomplete medical record data,with a complete rate of 88.61%.After the implementation of quality control circle activities,the number of incomplete medical record data was 15,with a complete rate of 98.18%,significant lower than before the implementation(P<0.05).The progress rate was 10.80%,and the target achievement rate was 101.96%.Conclusion In the management of medical records,the management model with quality control circle is effective for analyzing the incomplete medical record data.After its implementation of quality control circle-based management,the completeness of the medical records can be obviously improved.The circle members’confidence,communication skills,QCC technique application ability,team cohesion and personal ability can also be better improved.

关 键 词：品管圈 病案资料 提高完整率 应用效果 

分 类 号：R197.323.1[医药卫生—卫生事业管理]