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目的:分析管理循环(PDCA)结合根本原因分析法(RCA)对护理病历书写实施质控管理时的实践效果。方法:对本院2014年至2015年的病历书写实施PDCA循环结合RCA分析法进行质控管理,随机抽取2012年至2014年未实施时各年病历各150份,与2014年至2015年随机抽取的150份病历对比,评价病历书写质量。结果:质控管理后,其书写质量明显提高,书写缺陷发生率较管理前明显下降,差异具有统计学意义(P<0.05)。结论:采用PDCA循环管理结合RCA分析法,能够有效提高护理人员的书写水平,保证病历的客观性、真实性、准确性、完整性以及规范性,进而有效降低病历书写缺陷。
OBJECTIVE: To analyze the practical effect of management cycle (PDCA) combined with root cause analysis (RCA) on quality control management of nursing records. Methods: The PDCA cycle combined with RCA analysis was used to conduct quality control management in medical records from 2014 to 2015 in our hospital. A total of 150 medical records of each year from 2012 to 2014 were randomly selected and randomly selected from 2014 to 2015 Of the 150 medical record comparison, evaluation of medical record writing quality. Results: After the quality control management, the quality of writing was significantly improved, and the incidence of writing defects was significantly lower than that before the management, the difference was statistically significant (P <0.05). Conclusion: The combination of PDCA cycle management and RCA analysis can effectively improve the writing quality of nurses and ensure the objectivity, authenticity, accuracy, completeness and normativeness of medical records, thus effectively reducing the writing defects of medical records.