PDCA在提升产科运行病历书写时限性中的应用  

Application of PDCA Model in Improving the Timeliness of Operational Medical Record Writing

作　　者：张苑 孟繁荣[1] 牡丹[1] 宁明哲[1] Zhang Yuan;Meng Fanrong;Mu Dan;Ning Mingzhe(Nanjing Drum Tower Hospital,The Affiliated Hospital of Nanjing University Medical School,Nanjing 210008,Jiangsu,China;不详)

机构地区：[1]南京大学医学院附属鼓楼医院,江苏省南京市210008

出　　处：《中国病案》2024年第2期18-20,共3页Chinese Medical Record

基　　金：南京大学中国医院改革发展研究院课题项目;南京鼓楼医院医学发展医疗救助基金会资助项目(NDYG2022003、NDYG2021006)。

摘　　要：目的 采用PDCA模式对运行病历进行管理,提高运行病历书写时限性,保障医疗安全。方法2021年1月1日-2021年12月31日某院产科7939份运行病历作为对照组。开展PDCA循环管理对书写时限性进行质量监控,将实施改进措施后的2022年1月1日-2022年12月31日8160份产科运行病历作为观察组。比较两组运行病历书写完成情况并进行评价。结果 观察组运行病历中入院24小时内提交入院记录、入院24小时内提交医患沟通、入院8小时提交首次病程记录、术后3天内上级医师查房记录、入院后连续三天记录病程的及时提交率分别为99.85%、95.44%、95.10%、76.63%、72.84%均显著高于管理前的55.89%、24.78%、46.19%、72.33%、19.42%,两组比较差异具有统计学意义,P<0.01。结论 PDCA模式在产科运行病历书写时限性管理中,能够有效提高运行病历书写及时率。Objectives The purpose of this study was to use the Plan-Do-Check-Act(PDCA)model for managing the timeliness of medical record writing,improving the timeliness of medical record documentation,and ensuring patient safety.Methods The timely submission rates of the observation group's running medical records for submitting admission records within 24 hours of admission,submitting doctor-patient communication within 24 hours of admission,submitting the first course record within 8 hours of admission,recording the superior physician's room visit within 3 days after surgery,and recording the course of disease for three consecutive days after admission were 99.85%,95.44%,95.10%,76.63%,and 72.84%,respectively,were all significantly higher than the pre-management rates of 55.89%,24.78%,46.19%,72.33%,and 19.42%,and the difference between the two groups was statistically significant,P<0.01.Conclusions The PDCA model could effectively improve the CA electronic signature review and approval rate and timeliness rate of medical record documentation in obstetrics,thereby increasing patient safety.

关 键 词：PDCA 运行病历 亚专科 

分 类 号：R197.323[医药卫生—卫生事业管理]