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目的探讨PDCA循环在终末病案初级质控中的应用效果。方法运用PDCA循环对终末病案初级质控环节进行干预,对干预措施实施前后的结果进行对照研究。采用χ~2检验对PDCA实施前后的初级质控缺陷率和丙级病案缺陷发生率进行统计学检验。结果终末病案初级质控出的问题以缺少医师签字、出院记录出院时间有误、缺少医嘱单等为主,占到了80%以上。应用PDCA循环后,终末病案初级质控总缺陷率由干预前的6.61%降低到6.19%,差异具有统计学意义(P<0.05);丙级病案发生率由干预前的2.25%降低到0.83%,差异具有统计学意义(P<0.001)。结论 PDCA循环用于终末病案初级质控,能够明显地优化病案质量管理流程,值得进一步推广。
Objective To investigate the effect of PDCA circulation on the primary quality control of terminal medical records. Methods The PDCA cycle was used to intervene the primary quality control of the final medical record, and the results were compared before and after the intervention. The χ ~ 2 test was used to test the primary control defect rate and the incidence of defect grade C before and after PDCA. As a result, the quality control of the primary medical record was dominated by the lack of physician’s signature, the discharge from the hospital was recorded incorrectly and the lack of medical advice was the main issue, accounting for more than 80%. After applying PDCA cycle, the total defect rate of primary quality control in final medical record was reduced from 6.61% before intervention to 6.19%, the difference was statistically significant (P <0.05); the incidence of Grade C medical record was reduced from 2.25% before intervention to 0.83 %, The difference was statistically significant (P <0.001). Conclusions The PDCA cycle is used for the primary quality control of the final medical record, which can obviously optimize the medical record quality management process and is worth further promotion.