Objective To investigate the application of PDCA in the improvement of medical record management. Methods 320 medical records managed with routine method from January 2014 to January 2015 were set as the control group, while 320 medical records managed with PDCA from March 2015 to March 2016 were set as the experimental group, then compared the quality of medical records management respectively.Results In the experimental group, 307 (95.94%) were A grade medical records, 13 (4.06%) were B grade, and 0 (0.00%) were C grade, 95.94% of them were high quality medical records. In the control group, 286 (89.38%) were A grade medical records, 23 (7.19%) were B grade, and 11 (3.44%) were C grade, 89.38% of them were high quality medical records, the differences were statistically significant (χ2=10.127; P=0.001). The time of pigeonholing in experimental group was obviously decreased than that of control group, experimental group lose 0 medical record while control group lose 5, the differences were statistically significant (t =-21.309,χ2=5.039;P<0.05).Conclusions To use PDCA in medical records management could obviously increase the quality of medical records. The time of pigeonholing and losing rate were decreased. Besides, the degree of satisfaction of patients and medical workers were obviously increased.%目的 探究PDCA方法在促进病案管理中的应用.方法 选取2014年1月-2015年1月常规管理病案320份为对照组,2015年3月-2016年3月PDCA管理后病案320份为实验组,分别比较两组的病案管理质量.结果 实验组甲级病案307份(95.94%),乙级13份(4.06%),丙级0份;对照组甲级病案286份(89.38%),乙级23份(7.19%),丙级11份(3.44%).实验组的病案书写质量明显高于对照组,数据比较差别有统计学意义(χ2=10.127;P=0.001).实验组病案归档时间明显较对照组短;实验组的病案丢失数为0份,对照组丢失数为5份(1.56%),实验组病案丢失情况明显好于对照组,两组数据差异比较有统计学意义(t=-21.309、χ2=5.039;P<0.05).结论 使用PDCA循环管理方法管理病案,能显著提高病案书写质量,病案的归档时间和丢失率明显降低,同时医护人员以及病患对病案管理的满意度大大提升.
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