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目的:探析PDCA循环的病案管理流程规范化。方法:随机选取2011年1月至2014年12月来我院就诊的100例患者的病案,其中31例手术患者病案,20例危重患者病案,整理分析质量问题,并利用PDCA循环进行比较。结果:PDCA循环实施前的返修率是18%,实施后是3%,差异性显著(P<0.05)。实施前,80例甲类,占80%,14例乙类,占14%,6例丙类,占6%,实施后,98例甲类,占98%,1例乙类,占1%,1例丙类,占1%,差异性显著(P<0.05)。结论:基于PDCA循环的病案管理的开展,能够有效提高病案管理的质量,促使病案管理流程的规范化发展,及时发现病案管理中存在的问题,针对问题制定有效措施,为医务人员营造良好的工作环境。
Objective: To explore the standardization of case management process of PDCA cycle. Methods: A total of 100 cases of patients admitted to our hospital from January 2011 to December 2014 were randomly selected, including 31 cases of surgical patients and 20 cases of critically ill patients. Quality problems were analyzed and analyzed by PDCA cycle. Results: The rate of rework before PDCA cycle was 18% and 3% after the implementation, with significant difference (P <0.05). Before implementation, 80 cases of A, 80%, 14 cases of B, accounting for 14%, 6 cases of C, accounting for 6%, after the implementation of 98 cases of A, accounting for 98%, 1 case of B, accounting for 1% , 1 case of C, accounting for 1%, the difference was significant (P <0.05). Conclusion: The PDCA cycle-based medical record management can effectively improve the quality of medical record management, promote the standardized development of the medical record management process and find out the problems in the medical record management in time, formulate effective measures to solve the problems and create a good working environment for the medical staff .