| 引用本文: | | 从丽君,吴玉美,吴良明,陆双华.[cn_title][J].[journal_cn_name],2019,[volume]([issue]):860-863.[点击复制] |
| | Cong Lijun,Wu Yumei,Wu Liangming,Lu Shuanghua.[en_title][J].[journal_en_name],2019,[volume]([issue]):860-863.[点击复制] |
|
| 摘要: |
| 目的：探讨应用PDCA循环理论管理护理病案的效果。方法：建立护理病案管理的PDCA循环模型，运用到提升护理文书书写质量和护理病案管理过程中。结果：实施PDCA循环后护理病历缺陷率从30.67%下降到15%，各项目缺陷总数从375减少到164，护理文书书写质量显著提升（P < 0.001）；7个工作日及3个工作日病案回收率分别从2017年上半年的84.67%、68.67%上升到94%和86%，及时归档率亦明显提高（P < 0.001）。在这过程中护理人员不规范的书写习惯也得到了很好解决。结论：PDCA循环有效提高了护理病历质量和促进病案回收管理，护理人员的科研水平也得到提升。 |
| 关键词: PDCA循环 护理文书 书写质量 病案 回收管理 |
| DOI： |
|
| 基金项目: |
|
| Application of PDCA Circulation in the Management of Nursing Medical Records |
| Cong Lijun,Wu Yumei,Wu Liangming,Lu Shuanghua |
| (Information Department of Jiangsu Province Hospital Pukou Branch Hospital Nanjing Pukou District Central Hospital;Department of Medical Records and Statistics，Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School) |
| Abstract: |
| Objectives：To investigate the effect of PDCA Circulation on the management of nursing medical records. Methods：The model of PDCA circulation for nursing medical records management was established and applied in the process of improving the quality of nursing document writing and the management of nursing records. Results：After implementing the PDCA circulation，the defect rate of nursing medical records dropped from 30.67% to 15%. And the total number of defects decreased from 375 to 164. The quality of nursing document writing has been improved significantly（P < 0.001）. Meanwhile，the 7days and 3days medical records archiving rate was 94% and 86%，compared with 84.67% and 68.67% in the first half of 2017. The timely archiving rate of medical records has also been improved conspicuously（P < 0.001）. In this process，nurses’ irregular writing habits were also greatly improved. Conclusions：PDCA circulation effectively improves the quality of nursing medical records，and promotes the archiving management of medical records. In addition，the research level of the nurses has been improved. |
| Key words: PDCA Circulation nursing document writing quality medical records archiving management |
