Application of PDCA in Running Medical Record Writing Time Limit Management
Objectives This study aims to evaluate the application effect of Plan-Do-Check-Act cycle in improving the management of writing time limits of operating medical records by inspecting the overtime medical records of a tertiary general hospital,so as to facilitate medical record management.Methods A total of 565,986 medical records were extracted from the electronic medical record management system of a large tertiary hospital in Guangdong Province from January 1,2017 to June 30,2021.The time limit for completion of medical record writing was checked.A hospital launched a PDCA cycle in December 2017 with the goal of improving the timely writing of inpatient medical records and the patients were divided into two groups based on this.Chi-square test was used to analyze the differences in medical records writing before the implementation of cycle management(from January 1,2017,to December 31,2017)and after the implementation of cycle management(from January 1,2018,to June 30,2021).Results The average training and assessment score of medical staff increased from 74.83 points to 86.10 points,and the proportion of residents with scores of 80 or above increased from 28.96％to 82.02％.The number of timeout copies of running medical records dropped significantly.Admission records,first course records,operation records,and first postoperative course records decreased by 96.47％,89.30％,97.55％,and 88.35％year-on-year.It dropped from 1,423 in the first quarter of 2017 to 60 in the second quarter of 2021,and the proportion of unqualified applicants dropped from 4.37％to 0.42％.The difference was statistically significant.Conclusions The Plan-Do-Check-Act management is beneficial to improve the timeliness of medical staff in writing and running medical records and has the application value of strengthening the quality control management of medical records.
Running medical recordsPDCA cycleQuality management
NETL
NSTL
万方数据
维普
