PDCA循环在整体护理病历质量管理中的应用

目的 探讨PDCA循环在整体护理病历质量管理中的应用效果。方法 随机抽查2001年整体护理病历100份进行分析，在此基础上于2002年1月开始采用PDCA循环进行病历质量管理。结果 2002年1－4月整体护理病历质量统计，入／住院评估与病人状况符合率、护理诊断／问题符合率、护理措施符合率、护理措施实施率、PIO记录合格率、健康教育覆盖率、出院指导内容合格率较PDCA循环管理前上升6％－13％，经统计学处理，差异均有显著性意义（P＜0．05，P＜0．01）。结论 PDCA循环管理是提高和控制整体护理病历质量的有效方法。

Application of PDCA Circulation in the Quality Management of Holistic Nursing Care Records

Objective To investigate the application of plan do check action (PDCA) circulation in quality ma nagement of holistic nursing care records. Methods one hundred holistic nursing care records in 2001 were randomly selected and analyzed. From Jan. 2002, quality management of the records by PDCA circulation was implemented. Results Statistical analysis of quality of holistic nursing care records during Jan. 2002 to April 2002 revealed that the percentage of coincidence of hospitalization evaluation and status of patients, the percentage of coincidence of nursing diagnosis/problem, the percentage of coincidence of nursing activity, the percentage of practice of nursing activity, the percentage of qualification of PIO records, the percentage of coverage of healthy education, and the percentage of qualification of discharge instruction increased 6% to 13% than that before PDCA circulation management. There was significant difference statistically ( P <0.05, P <0.01). Conclusion PDCA circulation is an effective way to increase the quality management of holistic nursing care records.