摘要
目的 运用鱼骨图和柏拉图质量管理工具分析病历书写不及时的难点,以提高病历书写及时率。方法 提取某院2020年11月1日-2020年12月31日11237份住院病案为基线数据,运用鱼骨图和柏拉图进行分析,从人机料法环5个方面分析原因,利用二八法则,找出信息系统不完善、沟通及培训制度不完善、病案质控体系不完善、奖惩措施不完备4项要因,累计百分比为80.27%。针对要因拟定有效对策,比较实施对策前2021年1月1日-2021年3月31日3155份病案和实施后2021年6月1日-2021年8月31日3180份病案的书写及时率变化情况。结果 未运用鱼骨图和柏拉图质量管理工具实施改进前,病历书写及时率为83.39%;实施改进后病历书写及时率提升为91.32%,两组及时率比较,χ^(2)=90.248, P<0.05,差异具有统计学意义。结论 鱼骨图和柏拉图的运用能够有效提高病历书写及时率,通过优化信息系统、加强沟通与培训教育、完善病案考评机制、建立病案质控体系等方式加强病案时限管理力度,保障病案质量。
Objectives To apply Fishbone diagram and Plato quality management tool to analyze the difficulty of not timely writing medical records, in order to improve the timely writing rate. Methods 11,237 medical records from a hospital from November 1st, 2020 to December 31st, 2020 were extracted as the baseline data. Fish bone map and Plato were used to analyze the main causes and formulate effective countermeasures. The changes of writing timeliness rate of 3155 medical records from January 1st, 2021 to March 31st, 2021 before the implementation of countermeasures and 3180 medical records from June 1st, 2021 to August 31st, 2021 after the implementation of countermeasures were compared and analyzed. Results Before the implementation of improvement with fishbone diagram and Plato quality management tool, the timely rate of medical record writing was 83.39%;After the implementation of the improvement, the timely rate of medical record writing was increased to 91.32%, and the timely rate of the two groups was compared, χ^(2)=90.248, P<0.05, and the difference was statistically significant.Conclusions The application of fishbone diagram and Plato could effectively improve the timely rate of writing medical records, strengthen the time limit management of medical records and ensure the quality of medical records by optimizing information system, strengthening communication and training education, perfecting medical records evaluation mechanism and establishing medical records quality control system.
作者
匡永利
陶晓钦
程小维
胡水芳
邓明德
Kuang Yongli;Tao Xiaoqin;Cheng Xiaowei;Hu Shuifang;Deng Mingde(The Second Affiliated Hospital of Army Medical University,Chongqing 400037,China;不详)
出处
《中国病案》
2022年第12期14-16,共3页
Chinese Medical Record
关键词
鱼骨图
柏拉图
病案时限
质控
Fishbone diagram
Plato
Time limit of medical records
Quality control
