Application research on improving the quality of intelligent and automatic audit of medical record homepage data by means of PDSA
10.3969/j.issn.1671-332X.2024.10.014
- VernacularTitle:运用PDSA提升病案首页数据智能化审核质量的应用研究
- Author:
Jiefen TANG
1
;
Xiukui HU
;
Weiyuan HE
;
Chunlin HE
Author Information
1. 中山市人民医院 广东中山 528400
- Keywords:
PDSA;
Medical record data quality;
Intelligent review
- From:
Modern Hospital
2024;24(10):1527-1530,1534
- CountryChina
- Language:Chinese
-
Abstract:
Objective To explore the role of PDSA quality management tool in promoting the construction of hospital medical record quality control audit system,and the path to continuously improve the quality of intelligent audit of medical record first page data.Methods Analyzing the current state of medical record quality management using root cause verification meth-ods,we followed the PDSA quality management theory and process,implementing planning,execution,evaluation,and handling procedures.Special pilot programs,effectiveness validation,and iterative improvement measures were undertaken to enhance the entire process of intelligent medical record quality control review.Results After implementing PDSA cycle management meas-ures,the completion rates for admission records,surgical records,discharge records,and medical record cover pages within 24 hours all reached the preset target values.The accuracy of the main diagnosis selection by physicians significantly improved,re-sulting in a standardized and visualized work mechanism for intelligent medical record quality control.Conclusion The applica-tion of PDSA cycle management can effectively improve and enhance the quality of intelligent review of medical record cover pa-ges,facilitating the construction of a scientific system for intelligent medical record quality control review.
