PDCA在医学成人高等教育学院实习病历质量管理中的应用  

Application of PDCA in Quality Management of Clinical Practice in Adult Higher Education College

作　　者：贺雪黛 刘晓清[2] 张冰 HE Xuedai;LIU Xiaoqing;ZHANG Bing(Xuzhou Hospital of Traditional Chinese Medicine,Xuzhou 221000,Jiangsu,China;School of Continuing Education,Nanjing University of Traditional Chinese Medicine,Nanjing 210023,Jiangsu,China)

机构地区：[1]徐州市中医院,江苏徐州221000 [2]南京中医药大学继续教育学院,江苏南京210023

出　　处：《中国卫生产业》2024年第11期24-27,共4页China Health Industry

基　　金：江苏省高等教育学会2021年成人高等教育研究课题(CJY-6)。

摘　　要：目的探讨基于PDCA循环理论的病历书写管理对成人高等教育学员实习质量的应用效果。方法选取2021年6月—2022年6月南京中医药大学继续教育学院医学类的65名实习学员和708份病历,根据管理时间分为两组,将2021年6—12月的351份病历采用常规病历管理,为常规病历管理组;将2022年1—6月的357份病历采用PDCA循环法管理,为PDCA循环组。对比两组病历常规质控情况(病历书写评分、病历缺陷指数评分)、首页完整率、首页填写准确率及学员对病历质量管理满意度。结果PDCA循环组病历书写评分高于常规病历管理组,病历缺陷指数评分低于常规病历管理组,差异有统计学意义(P均<0.05)。PDCA循环组病案首页完整率、首页准确率、学员对病历质量管理满意度高于常规病历管理组,差异有统计学意义(P均<0.05)。结论PDCA循环法的应用不仅规范了实习生的病历质量管理,提升了实习学员对病历管理满意度,且对成人高等教育的改革与发展亦起到较好的推动作用。Objective To explore the application effect of medical record writing management based on PDCA cycle theory on the practice quality of adult higher education students.Methods A total of 65 interns and 708 medical records in the medical class of the School of Continuing Education of Nanjing University of Traditional Chinese Medicine from June 2021 to June 2022 were selected and divided into two groups according to the management time.The 351 medical records from June to December 2021 were managed by routine medical records as routine medical records management group,and 357 medical records from January to June 2022 were managed by PDCA cycle method as PDCA cycle group.The routine quality control of medical records(medical record writing score,medical record defect index score),home page integrity rate,home page filling accuracy rate and students'satifaction with medical record quality management were compared between the two groups.Results The medical record writing score of the PDCA cycle group was higher than that of the routine medical records management group,and the medical record defect index score was lower than that of the routine medical records management group,and the differences were statistically significant(both P<0.05).The integrity rate,accuracy rate of the first page and students'satifaction with the medical record quality management in the PDCA cycle group were higher than those in the routine medical records management group,and the differences were statistically significant(all P<0.05).Conclusion The application of PDCA cycle method not only standardizes the quality management of students'satifaction with quality management medical records, improves the practice effect, improves the satisfaction of students' medical records management, but also plays a good role in promoting the reform and development of adult higher education.

关 键 词：PDCA循环 病历书写 质量管理 按疾病诊断相关分类 

分 类 号：R19[医药卫生—卫生事业管理]