PDSA方法在住院病历书写时限管理中的应用  

Application of PDSA Method in the Time Limit Management of Inpatient Records Writing

作　　者：齐燕红 沈东庭 王彦灵 QI Yanhong;SHEN Dongting;WANG Yanling(Department of Quality Control Section,Yuzhong County First People's Hospital,Lanzhou 730104,Gansu,China)

机构地区：[1]榆中县第一人民医院质控科,甘肃兰州730104

出　　处：《中国卫生产业》2024年第6期92-95,共4页China Health Industry

摘　　要：目的探讨PDSA方法在住院病历书写时限管理中的应用效果。方法榆中县第一人民医院于2022年1月运用PDSA方法改进住院病历书写时限管理,比较实施改进前(2021年7-12月)9395份病案和实施改进后(2022年1-6月)7913份病案的书写及时率变化情况。结果实施PDSA方法改进前,病历书写及时率为44.75%,实施PDSA方法改进后,病历书写及时率提高至80.13%,其中,2022年6月,经过6个月的改进后,病历书写及时率提升至89.59%。结论通过PDSA方法,完善了医院电子病历时限质控管理机制,有效改善病历书写及时率,从而保障医疗质量与安全。Objective To explore the application effect of PDSA method in the time limit management of inpatient re-cords.Methods In January 2022,the First People's Hospital of Yuzhong County applied PDSA method to improve the management of the writing time limit of inpatient medical records,and the writing time rate changes of nine thousand three hundred and ninety-five medical records before implementation(July to December 2021)and seven thousand nine hundred and thirteen medical records after implementation(January to June 2022)were compared.Results Be-fore the implementation of PDSA method,the timely writing rate of medical records was 44.75%,and after the imple-mentation of PDSA method,the timely writing rate of medical records increased to 80.13%.Among them,in June 2022,after 6 months of improvement,the timely writing rate of medical records increased to 89.59%.Conclusion Through PDSA method,the time limit quality control management mechanism of hospital electronic medical record is improved,and the timely writing rate of medical record is effectively improved,so as to ensure the quality and safety of medical treatment.

关 键 词：PDSA方法 电子病历 时限管理 

分 类 号：R197.323[医药卫生—卫生事业管理]