提高住院医师电子病历文档及时性：PDCA 循环管理的作用。

Enhancing the timeliness of EMR documentation in resident doctors: the role of PDCA cycle management.

机构信息

West China School of Medicine, Sichuan University, Chengdu, 610041, China.

Department of Head and Neck Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China.

出版信息

BMC Med Educ. 2024 Nov 26;24(1):1367. doi: 10.1186/s12909-024-06134-2.

DOI:10.1186/s12909-024-06134-2

PMID:39592995

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11590573/

Abstract

BACKGROUND

The impact of the Plan-Do-Check-Act (PDCA) cycle in improving the timeliness of electronic medical record documentation (EMRd) remains uncertain. EMRd that is completed beyond the specified time is classified as late EMRd, while unqualified EMRd refers to electronic medical records with important sections that are not completed on time according to the Chinese Basic Norms of Medical Records Writing. This study aimed to evaluate the effectiveness of PDCA management in improving the timeliness of EMRd among resident doctors.

METHOD

This study utilized a before and after design. Resident doctors rotating in the Head and Neck Oncology Department of West China Hospital, Sichuan University, from November 2021 to August 2022 were classified as the control group and did not receive specific training on the timeliness of EMRd. Those rotating from September 2022 to June 2023 were assigned to the PDCA group, which was managed using the PDCA cycle. The effectiveness of PDCA cycle management was evaluated by comparing the incidence of late EMRd and unqualified EMRd between two groups. Univariate and multivariate binary logistic regression analyses were conducted tocontrol for confounding factors.

RESULTS

A total of 245 resident doctors were included, with 162 doctors in the PDCA group and 152 doctors in the control group. The incidences of late EMRd (5.40% vs. 2.56%, P = 0.005) and unqualified EMRd (1.05% vs. 0.00%, P < 0.001) were significantly lower in the PDCA group than those in the control group. After adjusting confounding factors, PDCA management still significantly reduced the occurrence of unqualified EMRd (P < 0.001) with an adjusted odds ratio (OR) of 0.166 (95% CI 0.067-0.416) and late EMRd (P < 0.001) with an adjusted OR of 0.318 (95% CI 0.181-0.557).

CONCLUSION

This study successfully developed PDCA management and demonstrated its effectiveness in improving the timeliness of EMRd while concurrently reducing the incidence of unqualified and late entries among resident doctors.

摘要

背景

计划-执行-检查-行动（PDCA）循环在提高电子病历记录（EMRd）及时性方面的影响尚不确定。超过规定时间完成的 EMRd 被归类为延迟 EMRd，而不合格的 EMRd 是指根据《病历书写基本规范》未按时完成重要部分的电子病历。本研究旨在评估 PDCA 管理在提高住院医师 EMRd 及时性方面的有效性。

方法

本研究采用前后设计。2021 年 11 月至 2022 年 8 月在四川大学华西医院头颈部肿瘤科轮转的住院医师为对照组，未接受 EMRd 及时性的专门培训。2022 年 9 月至 2023 年 6 月轮转的住院医师被分配到 PDCA 组，使用 PDCA 循环进行管理。通过比较两组间迟交 EMRd 和不合格 EMRd 的发生率来评估 PDCA 循环管理的有效性。采用单因素和多因素二元逻辑回归分析控制混杂因素。

结果

共纳入 245 名住院医师，PDCA 组 162 名，对照组 152 名。PDCA 组迟交 EMRd（5.40% vs. 2.56%，P=0.005）和不合格 EMRd（1.05% vs. 0.00%，P<0.001）的发生率明显低于对照组。调整混杂因素后，PDCA 管理仍显著降低不合格 EMRd 的发生（P<0.001），调整后比值比（OR）为 0.166（95%CI 0.067-0.416）和迟交 EMRd（P<0.001），调整后 OR 为 0.318（95%CI 0.181-0.557）。