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中文摘要: 目的：进一步规范病历质量管理，改变传统管理模式，建立病历质量长效管理机制。方法：将PDCA循环应用到病历质量管理中，按照计划、执行、检查、总结四个阶段，围绕目标的实现，制定详细的工作计划，将病历环节管理与终末管理相结合，不断查找突出问题，分析主要原因，并持续整改。结果：医务人员认真书写病历的意识增强，形成严谨、规范的工作氛围，病历质量不断提升，形成管理良性循环，医疗质量持续提升。结论：PDCA循环应用到病历质量管理工作后，不仅有助于提升病历质量，对于全院形成严格落实核心制度的良好氛围也具有积极意义。
Abstract:Objective：To standardize thequality management of medical records further，change the traditional management model and establish a long-term management mechanism for the quality of medical records. Methods：To apply PDCA Cycle to quality management of medical records.According to the four stages of planning，execution，inspection and summary，formulate a detailed work plan around the achievement of goals.Combining the management of medical records and terminal management，continuously find outstanding problems，analyze the main reasons，and continue to rectify. Results：It has enhanced the awareness of medical personnel to write medical records carefully，formed a rigorous and standardized working atmosphere，continuously formed a virtuous management cycle，and continuously improved medical quality. Conclusion：After PDCA Cycle is applied to the management of medical record quality，it is not only helps to improve the quality of medical records，but also has a positive significance for forming a good atmosphere for the entire hospital to strictly implement the core system.
keywords: medical records quality management PDCA cycle
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基金项目:南通市重点医学人才基金（2017013） 南通市重点医学人才基金（2017013）
引用文本：
朱 慧,黄松平,金 燕,王志荣,李 民*.PDCA循环在我院病历质量管理中的应用△[J].江苏卫生事业管理,2020,31(5):610-613.
Zhu Hui,Huang songping,Jin yan,Wang zhirong,Li min*.Application of PDCA Cycle to quality management of medical recordsin the hospital△[J].Jiangsu Health System Management,2020,31(5):610-613.
朱 慧,黄松平,金 燕,王志荣,李 民*.PDCA循环在我院病历质量管理中的应用△[J].江苏卫生事业管理,2020,31(5):610-613.
Zhu Hui,Huang songping,Jin yan,Wang zhirong,Li min*.Application of PDCA Cycle to quality management of medical recordsin the hospital△[J].Jiangsu Health System Management,2020,31(5):610-613.
