摘要
目的 采用 PDCA 模式对运行病历进行管理,提高运行病历书写时限性,保障医疗安全.方法 2021 年 1 月 1 日-2021 年 12 月 31 日某院产科 7939 份运行病历作为对照组.开展PDCA循环管理对书写时限性进行质量监控,将实施改进措施后的 2022 年 1 月 1 日-2022 年 12 月 31 日 8160 份产科运行病历作为观察组.比较两组运行病历书写完成情况并进行评价.结果 观察组运行病历中入院 24 小时内提交入院记录、入院 24 小时内提交医患沟通、入院 8 小时提交首次病程记录、术后 3 天内上级医师查房记录、入院后连续三天记录病程的及时提交率分别为 99.85%、95.44%、95.10%、76.63%、72.84%均显著高于管理前的 55.89%、24.78%、46.19%、72.33%、19.42%,两组比较差异具有统计学意义,P＜0.01.结论 PDCA模式在产科运行病历书写时限性管理中,能够有效提高运行病历书写及时率.
Abstract
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.
基金项目
南京大学中国医院改革发展研究院课题项目()
南京鼓楼医院医学发展医疗救助基金会资助项目(NDYG2022003)
南京鼓楼医院医学发展医疗救助基金会资助项目(NDYG2021006)
NETL
NSTL
万方数据