PDCA cycle Medical Record Home Page Quality Management Defect Rate
皖南医学院弋矶山医院管理与创新项目（CX2022042）
目的：运用PDCA循环管理改进住院病案首页缺陷，提升住院病案首页质量。方法：选取2021年4月1日-6月30日和2021年7月1日-9月30日住院病案首页质控数据，比较PDCA循环管理前后缺陷情况，采用χ2检验统计分析，评价管理效果。结果：PDCA循环管理后，医院住院病案首页质量总体缺陷率下降0.76%，经χ2检验分析，差异具有统计学意义（χ2=51.559，P < 0.05）。手术及操作栏缺陷率下降最多，下降0.50%，但缺陷率仍占首位，外科手术及操作栏填写缺陷现象较内科普遍。出院诊断缺陷率不减反增，且上涨最多，内科出院诊断栏填写缺陷现象较外科普遍。结论：PDCA循环后，医院住院病案首页填写整体缺陷率下降。但首页问题仍存在，还需加强专项质控、加强环节管理和信息化建设，从而提升住院病案首页质量。
Objective：Using PDCA cycle management to improve the defects of the home page of medical records and improve the quality of the home page of medical records. Method：This paper selects the quality control data on the home page of inpatient medical records from April 1，2021 to June 30，2021 and from July 1，2021 to September 30，2021. Furthermore，the number and rate of defects on the home page of inpatient medical records before and after PDCA cycle management were compared. χ2 Test statistical methods are used for analysis to evaluate the management effect. Results：After PDCA circulation management，the overall defect rate of the quality of the home page of hospital inpatient medical records decreased by 0.76% compared with that before PDCA circulation. Through χ2. The difference is statistically significant（χ2=51.559，P < 0.05）. The defect rate of surgery and operation bar decreasedthe mostby 0.50%. However，the defect rate still takes the first place，and the defect of filling in surgical operation and operation column was more common than that of internal medicine. The rate of defects in discharge diagnosis increased rather than decreased，with the largest increase，and the defect in the medical discharge diagnosis column was more common than that in surgery. Conclusion：After the PDCA cycle，the overall defect rate of filling in the home page of inpatient medical records decreased，but the problem of the home page still exists，it is necessary to strengthen special quality control，strengthen link management，and strengthen information construction，so as to improve the quality of the home page of medical records.