PDCA在改善电子护理记录质量中的应用  

Application of PDCA in Improving the Quality of Electronic Nursing Records

作　　者：丛倩 曲利 姜人豪 李元飞 Cong Qian;Qu Li;Jiang Renhao;Li Yuanfei(Yantai Affiliated Hospital of Binzhou Medical College Binzhou 264100,Shandong Province,China;不详)

机构地区：[1]滨州医学院烟台附属医院,山东省滨州市264100

出　　处：《中国病案》2023年第2期21-23,共3页Chinese Medical Record

摘　　要：目的 探讨采用PDCA管理模式对提高电子护理记录质量的效果。方法 采用干预前后对比的方式进行研究,对某院护理记录的书写实施PDCA模式管理,随机抽取PDCA干预前(2018年6月1日至2018年12月31日)及PDCA干预后(2019年1月1日至2019年6月30日)的电子病历各1000份,统计两组电子护理记录合格率、存在的主要问题、护理文书质量评分。结果 干预6个月后,病案中入院评估表、体温记录单、医嘱记录单、危重患者护理记录单、一般病人护理记录单的合格率分别为98.10%、98.40%、97.50%、98.34%、98.81%均显著高于干预前的94.80%、93.30%、94.70%、92.54%、94.82%(P<0.05);干预6个月后,病案中护理记录不及时、复制粘贴、漏签代签、护理记录不一致问题检出率3.40%、2.30%、1.10%、0.50%均显著低于干预前10.10%、6.70%、3.00%、3.10%(P<0.05);干预6个月后,内科病案、外科病案中的护理文书评分分别为(97.30±2.61)分、(97.44±2.53)分较干预前均显著提高(P<0.05)。结论 采用PDCA管理模式进行干预后,电子护理记录中护理文书的质量得到显著提高,该管理模式具有一定的推广应用价值。Objective To explore the impact of adopting the PDCA management model on the quality of electronic nursing records. Methods A comparative study was conducted before and after the intervention. PDCA mode management was implemented for the writing of nursing records in a hospital. 1000 electronic medical records were randomly selected before PDCA intervention(from June 1st, 2018 to December 31st, 2018) and after PDCA intervention(from January 1st, 2019 to June 30th, 2019). Statistics of two groups of electronic nursing records qualified rate, the main problems, the quality of nursing documents score. Results Six months after the intervention, the qualified rates of admission assessment sheet, temperature record sheet, medical order record sheet, critical patient nursing record sheet and general patient nursing record were 98.10%, 98.40%, 97.50%,98.34% and 98.81%, respectively, which were significantly higher than 94.80%, 93.30%, 94.70%, 92.54%and 94.82% before intervention(P<0.05);After 6 months of intervention, the detection rates of nursing records were 3.40%, 2.30%, 1.10% and 0.50%, which were significantly lower than those before intervention, 10.10%,6.70%, 3.00%, 3.10%(P<0.05). After 6 months of intervention, the scores of nursing documents in medical records and surgical records were(97.30±2.61) points and(97.44±2.53) points, respectively, which were significantly higher than those before intervention(P<0.05). Conclusions After the intervention of the PDCA management model in a hospital, the quality of electronic nursing records in the electronic medical records had been significantly improved, and the problem detection rate in the nursing-related records had been significantly reduced. This management model had certain promotion and application value.

关 键 词：PDCA 电子病历 护理记录 病案质量 

分 类 号：R47[医药卫生—护理学]