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。
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.