摘要
根据《江苏省住院病历质量评定标准》,结合某三级医院病历质量现状,运用PDCA循环管理开展病历质量培训。通过访谈法和病历抽查,获得该院病历质量中存在的问题。采用PDCA管理循环模式开展3次病历质量主题培训:重度缺陷专项培训、主要扣分专项培训、危重病历专项培训。运用卡方检验分析3次培训的效果,证明该结果具有统计学意义。文章为医院提升病历书写质量、加强病历质量管理提供参考途径。
According to the Jiangsu Province Inpatient Medical Records Quality Evaluation Standard,combined with the status of medical records quality in a tertiary hospital,the PDCA cycle management is used to carry out medical records quality training.Through interviews and spot check of medical records,the problems in the quality of the hospital's medical records were obtained.The PDCA cycle management mode was adopted to carry out three medical records quality trainings:special training for the severe defects,special training for the major deductions,and special training for the medical records of the critically ill patients.The Chi⁃square test was used to examine the effect of the three trainings,which proved that the result was statistically significant.The article provides reference for hospitals to improve the quality of medical records writing and strengthen the medical records quality management.
作者
叶茜
鲁翔
YE Qian;LU Xiang(School of Public Health,Nanjing Medical University,Nanjing 211166;Party Committee Office,Sir Run Run Hospital of Nanjing Medical University,Nanjing 211166,China)
出处
《南京医科大学学报（社会科学版）》
2021年第4期383-387,共5页
Journal of Nanjing Medical University（Social Sciences）
基金
健康江苏建设与发展研究院政策研究项目“新医改背景下公立医院运行管理的战略变革”(2017JKJS002Z),“‘健康江苏’语境中的健康医疗数据共享研究”(2017JKJS001Y)。
关键词
病历质量
培训
PDCA循环管理
三级医院
medical records quality
training
PDCA cycle management
tertiary hospital
