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目的通过PDCA循环等管理工具及手段,全面提高某院恶性肿瘤放化疗病案质量和肿瘤专科医务人员病案书写水平,并推广相应经验。方法运用PDCA循环基本理论,综合运用新旧QC七大工具中的检查表、鱼骨图等统计管理方法,对恶性肿瘤放化疗病案存在的问题、各类影响因素、整改措施及效果检验等方面进行全面分析,并将病案质量数据进行统计分析。结果实施PDCA循环后某院恶性肿瘤放化疗病案质量明显改善,经过2个PDCA循环后,甲级病案率达97.5%,P<0.05,差异有统计学意义。各项具体缺陷原因分析中,无病理或不详缺陷从13份下降至7份、无开具资质从106份下降至13份、无上级医师签字从19份下降至1份、实验室资料未查或不详从29份下降至2份、缺告知书从23份下降至5份。结论 PDCA等管理工具的运用使某院恶性肿瘤放化疗病案质量明显提高,使得恶性肿瘤放化疗更加标准化、规范化。
Objective Through PDCA cycle and other management tools and means to comprehensively improve the radiotherapy and chemotherapy of a hospital medical record quality and medical records of medical staff record level and promote the corresponding experience. Methods The PDCA cycle basic theory, the comprehensive use of the old and new QC seven tools in the checklist, fishbone chart and other statistical management methods, the radiotherapy and chemotherapy of malignant tumor medical problems, all kinds of influencing factors, rectification measures and effect test and so on Comprehensive analysis, and the medical record quality data for statistical analysis. Results After the PDCA cycle, radiotherapy and chemotherapy of malignant tumors in a hospital significantly improved the quality of medical records. After two cycles of PDCA, the grade A medical record rate reached 97.5%, P <0.05, the difference was statistically significant. The analysis of specific causes of defects, no pathology or unknown defects decreased from 13 to 7, no qualifications from 106 to 13, no physician signed from 19 to 1, the laboratory data is not checked or Unknown dropped from 29 to 2, lack of advice from 23 to 5. Conclusions The application of PDCA and other management tools has significantly improved the quality of medical records of radiotherapy and chemotherapy of malignant tumors in a hospital and made the standardization and standardization of radiotherapy and chemotherapy of malignant tumors.