Objective:To study the impact of different management methods on the quality of inpatient medical records in the Infection Prevention and Control Department.Method:A total of 76 inpatient medical records of patients who were admitted to the Infection Prevention and Control Department of our hospital from January 2023 to January 2024 were selected as the experimental subjects and randomly divided into a conventional management group and a PDCA management group(n=38).The scores of writing format,problem scores,quality scores,and other scores of the two groups of inpatient medical records were compared.Results:Compared with the conventional management group,the PDCA management group had lower scores in writing irregularities,writing errors,lack of physician signature on the doctor's order sheet,failure to modify the doctor's order as required,and lower rework rate of inpatient medical records;the accuracy rate of surgical coding,the accuracy rate of disease coding,3-day case submission rate,and quality score of inpatient medical records increased;the differences were significant(P<0.05).Conclusion:Through the intervention of PDCA management,it can effectively reduce the incidence of errors and improve the quality of inpatient medical records in the Infection Prevention and Control Department.
关键词
PDCA法管理/感染/住院病案/住院病案质量
Key words
PDCA management/Infection/Medical record/Quality of medical record
维普
万方数据