摘要
目的探讨实施PDCA循环对社区卫生服务中心门诊电子病案规范性和质量的提升效果。方法采用等距抽样法,从门诊电子病历系统中选取实施PDCA质量控制管理前(2022年)和实施后(2023年)的病案各540份作为对照组和观察组。依据《门诊病历质控标准》,对照组采用常规质量控制方法,观察组采用PDCA循环进行质量控制,对比分析两组病案的规范性、合格率、未及时修改率及完成率。结果观察组在专业术语使用、主诉、现病史、体格检查、诊断、注意事项、健康指导等不规范项目分别为1.11%、1.67%、7.41%、7.78%、2.22%、1.11%、1.30%,显著低于对照组4.07%、5.19%、12.04%、14.44%、5.00%、3.33%、4.63%。合格病案512份(94.81%)高于对照组473份(87.59%);未及时修改病案34份(6.30%)低于对照组126份(23.33%);病案完成率99.48%高于对照组98.79%,P<0.05,差异均具有统计学意义。结论PDCA循环通过明确质量管理各阶段的目标,并注重实践中的问题解决与策略调整,在提升门诊电子病案的规范性、合格率及完成率,同时降低未及时修改率方面展现出了显著成效,可广泛在门诊电子病案质量管理中应用。
Objectives This study aims to explore the improvement effect of implementing the PDCA cycle on the standardization and quality management of outpatient electronic medical records.Methods Using equidistant sampling method,540 medical records before(2022)and 540 records after(2023)implementation of PDCA quality control management were selected from the outpatient electronic medical record system as the control group and observation group.According to the"Outpatient Medical Record Quality Control Standards",the control group adopts conventional quality control methods,while the observation group adopts PDCA cycle for quality control.The standardization,qualification rate,untimely modification rate and completion rate of the two groups of medical records were compared and analyzed.Results The rates of non-standard items in the observation group such as use of professional terms,chief complaint,history of current illness,physical examination,diagnosis,precautions,and health guidance were 1.11%,1.67%,7.41%,7.78%,2.22%,1.11%,and 1.30%,respectively,which were significantly lower than those of the control group at 4.07%,5.19%,12.04%,14.44%,5.00%,3.33%,and 4.63%.The number of qualified medical records was 512(94.81%),which was higher than the 473(87.59%)in the control group.The number of medical records that were not modified in time was 34(6.30%),which was lower than the 126(23.33%)in the control group.The medical record completion rate was 99.48%,which was higher than the 98.79%in the control group(P<0.05).The differences were statistically significant.Conclusions The PDCA cycle has shown significant results in improving the standardization,qualification rate and completion rate of outpatient electronic medical records,while reducing the rate of untimely modification,by clarifying the goals of each stage of quality management and focusing on problem solving and strategy adjustment in practice.It can be widely used in the quality management of outpatient electronic medical records.
作者
高怀婷
Gao Huiting(Department of General Practice,Beijing Community Health Service Center Donghuashi street,Dongcheng District,Beijing 100022,China)
出处
《中国病案》
2025年第7期14-17,共4页
Chinese Medical Record
关键词
PDCA循环
门诊电子病案
质量管理
社区卫生服务中心
PDCA cycle
Outpatient electronic medical records
Quality Assurance
Community Health Service Center
