通讯作者: 周磊, 16910556@qq.com

DOI：10.12201/bmr.202409.00064

Construction of specific medical records assessment system for CAP patients disease severity based on PDCA

• 摘要：目的 探讨以专病病历为导向联合持续质量改进（PDCA）构建社区获得性肺炎（CAP）患者病情严重程度评估体系。方法 统计2022年1-6月呼吸与危重症医学科住院CAP患者162例，采用鱼骨图法分析病情严重程度评估率低的原因，通过以专病病历为导向联合PDCA制定改进措施，统计分析7-12月份CAP患者数据，比较PDCA实施前后CAP病情严重程度评估率及平均住院日、人均住院费用变化。结果 实施后，科室CAP患者PSI评估率（69.38%）明显高于实施前（14.20%），平均住院日（8）低于实施前（10天），人均住院费用（7116.91元）低于实施前（8639.63元），且差异有统计学意义（p＜0.01）。结论 基于PDCA以专病病历导向CAP患者病情严重程度评价体系，可提高CAP患者病情严重程度评估率，早期识别重症肺炎，有助于降低CAP患者平均住院日及人均住院费用，减轻患者医疗负担，提高患者满意度。

  关键词： 专病病历; PDCA; 社区获得性肺炎; 肺炎严重指数; 病情评估

   

  Abstract: Objective Exploring the construction of a community acquired pneumonia (CAP) patient severity assessment system guided by specialized medical records and combined with continuous quality improvement (PDCA). Methods A total of 162 CAP patients hospitalized in the Department of Respiratory and Critical Care Medicine from January to June 2022 were counted. The fishbone diagram method was used to analyze the reasons for the low assessment rate of disease severity. Improvement measures were formulated by combining with PDCA based on special medical records, and statistical analysis was carried out. The data of CAP patients from July to December were compared to the changes in the assessment rate of CAP disease severity, average hospitalization days, and per capita hospitalization expenses before and after the implementation of PDCA. Results After implementation, the PSI assessment rate of CAP patients in departments (69.38%) was significantly higher than that before implementation (14.20%), the average hospitalization days (8) were lower than that before implementation (10 days), and the per capita hospitalization expenses (7116.91 yuan) were lower than that before implementation (8639.63 yuan), and the difference was statistically significant (p＜0.01)。 Conclusion Based on PDCA, the evaluation system of CAP patients severity based on specific medical records can improve the evaluation rate of CAP patients severity, identify severe pneumonia early, help to reduce the average hospitalization days and per capita hospitalization expenses of CAP patients, reduce the medical burden of patients, and improve patient satisfaction.

  Key words: Specific medical records; PDCA; Community-acquired pneumonia; Pneumonia severity index; Condition assessment

  提交时间：2024-09-29

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• 序号	提交日期	编号	操作
  1	2024-08-26	bmr.202409.00064V1	下载

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