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目的 PDCA循环法在病历书写时限质量控制中的应用。方法分析病历书写时限存在的问题,运用PDCA方法对主要问题进行干预并观察效果。结果实施PDCA一年后,随机抽取2015年1月-2015年10月17 782份运行病历,病历书写时限持续改进达到了预期效果,其中:入院记录未在24小时内完成下降86.73%;首次病程记录未在8小时内完成下降93.77%;上级医师首次查房记录未在48小时内完成下降93.66%;术前讨论记录未在术前72小时完成下降94.63%;出院记录未在24小时内完成下降92.92%。结论 PDCA循环法能有效地促进病历书写时限的质控,更好的地提高病历书写质量。在病历书写时限的质控中,对于未解决的问题,在下一个PDCA循环中加以解决,从而构建病历书写时限质量的持续改进模式,是不断完善病案质检工作的基础。
Objective PDCA cycle method in medical record writing time limit quality control application. Methods Analyze the existing problems in the writing time of medical records, and use the PDCA method to intervene the main problems and observe the effects. Results One year after the implementation of PDCA, 17 782 medical records were randomly selected from January 2015 to October 2015, and the continuous improvement of medical records writing time achieved the expected results. Among them, the admission record did not finish 86.73% within 24 hours; the first course of disease The record did not finish down 93.77% within 8 hours; the first physician check-in record did not finish down 93.66% within 48 hours; the preoperative discussion record did not finish down 94.63% 72 hours before operation; the discharge record did not finish within 24 hours Down 92.92%. Conclusion The PDCA method can effectively improve the quality control of medical records writing time limit and improve the quality of medical record writing. In the quality control of medical records writing time limit, it is the basis of continually improving the quality control of medical record for solving unresolved problems and solving them in the next PDCA cycle so as to construct a continuous improvement mode of medical records writing quality.