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目的探讨追踪方法学配合PDCA循环管理对医院病案管理质量的影响。方法将我院2015年1~6月采用追踪方法学管理的病案设为对照组;2015年7~12月采用追踪方法学配合PDCA循环管理的病案设为观察组,比较两组病案的质量、病案质量缺陷率以及病案等级等情况。结果观察组病案质量评分显著高于对照组,差异有统计学意义(P<0.05)。观察组病案各项指标质量缺陷率显著低于对照组,差异有统计学意义(P<0.05)。观察组甲类病案率(93.3%)显著高于对照组(74.8%),乙类、丙类、返修病率显著低于对照组,观察组病案质量优于对照组(P<0.01)。结论采用追踪方法学配合PDCA循环管理能有效提高病案质量等级、减少病案检查单缺失、诊断不明确、复印困难等质量缺陷,提高病案管理质量。
Objective To explore the impact of tracking methodology and PDCA cycle management on the quality of medical records management in hospitals. Methods From January to June 2015, our hospital was treated as follow-up method. In July 2015 to July 2015, the follow-up method and PDCA cycle management were set as the observation group. The quality of medical records of the two groups was compared. Medical record quality defect rate and medical record level and so on. Results The score of medical record in the observation group was significantly higher than that in the control group, with significant difference (P <0.05). The quality defect rate of each index in the observation group was significantly lower than that in the control group, the difference was statistically significant (P <0.05). The case record of group A was significantly higher (93.3%) than that of the control group (74.8%), while those of group B and C were significantly lower than those of the control group. The quality of medical records in the observation group was better than that of the control group (P <0.01). Conclusion Follow-up method and PDCA cycle management can effectively improve the quality of medical record, reduce quality defects such as missing test record list, unclear diagnosis and difficult copying, and improve the quality of medical record management.