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目的:应用PDCA质量管理工具对住院病历门急诊病历连贯性管理的效果观察。方法:建立全程监测系统对住院病历门急诊病历连贯性每月进行数据监测,并将数据转化为有用的信息,通过图表形式,在全院下发,并对数据做纵向比较,依照PDCA循环进行整改。结果:门急诊病历的提供率从72.8%上升了到了96.4%,提供病历完整率从60.0%上升到了88.9%,经趋势检验,P<0.001。实施前后住院病历门急诊病历连贯性对比,门急诊病历的提供率和提供病历的完整率均有明显提高,P<0.001。结论:应用PDCA质量管理工具对住院病历门急诊病历连贯性进行管理有明显效果。
OBJECTIVE: To observe the effect of PDCA quality management tools on the coherence management of medical records in outpatient and emergency department. Methods: The establishment of a full monitoring system on the hospital records emergency medical records coherence monthly data monitoring, and data into useful information, through the chart form, issued in the hospital, and longitudinal comparison of data, in accordance with the PDCA cycle Rectification. Results: The rate of outpatient and emergency medical records was increased from 72.8% to 96.4%, and the complete medical record rate was increased from 60.0% to 88.9%. The trend test showed that the rate of medical record was P <0.001. Before and after the implementation of inpatient medical records emergency medical records consistency compared to the emergency medical records and provide the medical record the complete rate were significantly improved, P <0.001. Conclusion: The application of PDCA quality management tools to hospital records emergency medical records coherence management has obvious effect.