Application of PDCA Model in Improving the Timeliness of Operational Medical Record Writing
Objectives The purpose of this study was to use the Plan-Do-Check-Act(PDCA)model for managing the timeliness of medical record writing,improving the timeliness of medical record documentation,and ensuring patient safety.Methods The timely submission rates of the observation group's running medical records for submitting admission records within 24 hours of admission,submitting doctor-patient communication within 24 hours of admission,submitting the first course record within 8 hours of admission,recording the superior physician's room visit within 3 days after surgery,and recording the course of disease for three consecutive days after admission were 99.85%,95.44%,95.10%,76.63%,and 72.84%,respectively,were all significantly higher than the pre-management rates of 55.89%,24.78%,46.19%,72.33%,and 19.42%,and the difference between the two groups was statistically significant,P＜0.01.Conclusions The PDCA model could effectively improve the CA electronic signature review and approval rate and timeliness rate of medical record documentation in obstetrics,thereby increasing patient safety.
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