PDCA管理工具在提升手术室电子护理病历质量中的应用体会  

PDCA management tools in improving the quality of electronic care medical records of operating room

作　　者：汪晓玲 万代红 WANG Xiaoling;WAN Daihong(Operating Room,Central Hospital of Huangshi and Eastern Hubei Medical Group,Huangshi 435000,China)

机构地区：[1]湖北省黄石鄂东医疗集团市中心医院手术室,湖北黄石435000

出　　处：《麻醉安全与质控》2021年第6期397-402,共6页Perioperative Safety and Quality Assurance

摘　　要：目的探讨PDCA管理工具在提升手术室电子护理病历质量中的应用与效果。方法运用PDCA管理工具,不断分析手术室电子护理文书质量缺陷原因;通过构建结构化电子病历,嵌入护理病历质量控制模块,建立以数据量化为基础的手术室电子护理文书质量控制体系和质量监控指标,不断优化手术室电子病历操作界面和扫码功能,增强硬件基础建设,建立绩效考核闭环体系不断推动手术室电子护理病历质量提升。结果运用PDCA管理工具对手术室电子护理病历质量持续改进后,手术室电子护理文书合格率达到目标值;手术室信息系统使用满意度持续提升;闭环扫码完成率达到理想控制水平;手术室电子护理病历及时归档率达到95%以上。结论手术室电子护理病历质量管理中使用PDCA管理工具,能显著提升手术室护理病历质量。Objective To explore the application and effect of PDCA management tools in improving the quality of electronic nursing medical records in the operating room.Methods The adoption of PDCA management tools is for constantly analyzing the quality defects of operating room electronic care documents.Through building the structured electronic medical records quality control module,the data quantification based operating room electronic nursing documents quality control system and data monitoring index can be established,for constantly optimizing the operating room electronic medical records operation interface and code scanning function,enhancing hardware infrastructure and establishing a performance assessment closed loop system to promote the quality of operating room electronic care medical records.Results With the continuous improvements of the quality of electronic nursing medical records in the operating room,the qualified rate of electronic nursing documents reaches the target value;the satisfaction rate of the adoption of operating room information system continues to improve;the completion rate of closed-loop scanning code reaches the ideal control level,and the timely filing rate of electronic nursing medical records in the operating room is well over 95%.Conclusion The implementation of PDCA management tools in the quality management of operating room electronic nursing medical records can significantly improve the quality of operating room nursing medical records.

关 键 词：PDCA 提升 手术室 电子护理病历 质量 

分 类 号：R47[医药卫生—护理学]