基于PDCA循环的精细化管理对病案管理质量及医患纠纷的影响  

The impact of fine management based on PDCA cycle on the quality of medical record management and doctor-patient disputes

作　　者：杨青 YANG Qing(Tongren Maternal and Child Health Hospital,Guizhou,Tongren,554300,China)

机构地区：[1]铜仁市妇幼保健院,贵州铜仁554300

出　　处：《当代医学》2025年第1期91-94,共4页Contemporary Medicine

摘　　要：目的探讨基于PDCA循环的精细化管理在病案管理中的应用效果。方法选取2020年2月至2022年3月铜仁市妇幼保健院1892份病例资料作为研究对象,将2020年2月至2021年2月基于PDCA循环的精细化管理实施前的946份病例资料纳入对照组,2021年3月至2022年3月基于PDCA循环的精细化管理实施后的946份病例资料纳入观察组。比较两组病案管理质量、不良事件(病案首页缺页缺项、病案破损、病案返修、病案编码错误、病案信息录入错误)发生率、医患纠纷发生率、医护人员满意度。结果观察组病案首页合格率为98.52%,高于对照组的93.87%,差异有统计学意义(P<0.05);观察组病案首页缺页缺项、病案破损、病案返修、病案编码错误、病案信息录入错误发生率及医患纠纷发生率均低于对照组,差异有统计学意义(P<0.05);观察组医护人员满意度为96.94%,高于对照组的87.38%,差异有统计学意义(P<0.05)。结论基于PDCA循环的精细化管理在病案管理中的运用效果显著,能提高病案管理质量,减少病案不良事件的发生,提升医护人员满意度,降低医患纠纷率。Objective To explore the application effect of fine management based on PDCA cycle in medical record management.Methods 1892 cases data of Tongren Maternal and Child Health Hospital from February 2020 to March 2022 were selected as the study objects,946 cases data before the implementation of the refined management based on the PDCA cycle from February 2020 to February 2021 were set as the control group,and 946 cases data after the implementation of the refined management based on the PDCA cycle from March 2021 to March 2022 were set as the observation group.The quality of medical record management,the incidence of adverse events(missing items on the first page of the medical record,damaged medical record,repair of medical record,wrong coding of medical record and wrong entry of medical record information),the rate of doctor-patient disputes and the satisfaction of medical staff were compared between the two groups.Results The qualified rate of the first page of medical records in the observation group was 98.52%,which was higher than 93.87%in the control group,the difference was statistically significant(P<0.05).The missing items on the first page of the medical record,the damaged medical record,the repair of the medical record,the error rate of the medical record code,the error rate of the medical record information entry and the incidence rate of the doctor-patient dispute in the observation group were lower than those in the control group,the differences were statistically significant(P<0.05).The satisfaction of medical staff in the observation group was 96.94%,which was higher than 87.38%in the control group,the difference was statistically significant(P<0.05).Conclusion The application of fine management based on PDCA cycle in medical record management is effective,which can improve the quality of medical record management,reduce the occurrence of adverse events such as medical record repair,improve the satisfaction of medical staff,and reduce the rate of doctor-patient disputes.

关 键 词：病案管理 PDCA循环 精细化管理 病案管理质量 医患纠纷 

分 类 号：R197.323[医药卫生—卫生事业管理]