摘要目的:探讨鱼骨图与柏拉图及PDCA循环分析法在病案管理中的应用。方法:2019年1月至2023年12月，抽取济南市第二人民医院病历单4 000例，其按照时间顺序分为对照组(2 000例，常规管理)和研究组(2 000例，鱼骨图与柏拉图及PDCA循环分析法管理)。比较两组病案分级、病案整理时间、病案质量缺陷、病案管理情况。结果:与对照组的病案甲级率[89.45%(1 789/2 000)]比较，研究组的[97.70%(1 954/2 000)]更高，差异有统计学意义( P<0.05)，与对照组的病案乙级率[9.70%(194/2 000)])、丙级率[0.00%(0/2 000)]，研究组的[2.30%(46/2 000)]、[0.00%(0/2 000)]更低，差异有统计学意义( P<0.05)。与对照组比较，研究组的护理文书、其他病案资料整理时间更短，差异有统计学意义( P<0.05)。与对照组的医嘱不吻合率[1.45%(29/2 000)]、用药指征不完整率[1.65%(33/2 000)]、手术交接不清晰率[1.40%(28/2 000)]、知情同意书存在缺漏率[1.15%(23/2 000)]、检查单不完整率[1.55%(31/2 000)]、特殊检查没有及时记录率[1.10%(22/2 000)]、鉴别诊断不足率[1.05%(21/2 000)]、病案总缺陷率[9.35%(187/2 000)]比较，研究组的0.40%(8/2 000)、0.45%(9/2 000)、0.40%(8/2 000)、0.25%(5/2 000)、0.35%(7/2 000)、0.15%(3/2 000)、0.15%(3/2 000)、2.15%(43/2 000)更低，差异均有统计学意义(均 P<0.05)。与对照组的首页合格率[91.55%(1 831/2 000)]、归档正确率[92.60%(1 852/2 000)]、编码正确率[92.05%(1 841/2 000)]比较，研究组的97.75%(1 955/2 000)、98.05%(1 961/2 000)、98.15%(1 963/2 000)更高，差异均有统计学意义(均 P<0.05)。 结论:鱼骨图与柏拉图及PDCA循环分析法应用在病案管理中，可提高病案质量，缩短病案整理时间，降低病案缺陷率。

abstractsObjective:To explore the application of fishbone diagram, Plato and PDCA cycle analysis in medical record management.Methods:From January 2019 to December 2023, 4 000 medical records were collected and divided into control group (routine management) and study group (fishbone chart, Plato and PDCA cycle analysis management) in chronological order, 2 000 cases in each group.The medical record classification, medical record sorting time, medical record quality defects and medical record management of the two groups were compared.Results:Compared with the control group[89.45% (1 789/2 000)], the grade A rate of medical records in the study group[97.70% (1 954/2 000)] was higher, and the difference was statistically significant ( P<0.05).Grade B rate of medical records [9.70% (194/2 000)] and grade C rate of medical records [0.00% (0/2 000)] in the control group was higher than those in the study group's[2.30% (46/2 000)] and [0.00% (0/2 000)], and the differences were statistically significant( P<0.05).Compared with the control group, the time for arranging nursing documents and other medical records in the study group was shorter, and the differences were statistically significant ( P<0.05).The non-coincidence rate [1.45% (29/2 000)], incomplete medication indication rate [1.65% (33/2 000)], unclear surgical handover rate [1.40% (28/2 000)], missing informed consent form [1.15% (23/2 000)], incomplete checklist rate [1.55% (31/2 000)], untimely recording of special examinations [1.10% (22/2 000)], insufficient differential diagnosis rate [1.05% (21/2 000)] and total defect rate [9.35% (187/2 000)] of the control group were higher than those of the study group[0.40%(8/2 000), 0.45%(9/2 000), 0.40%(8/2 000), 0.25%(5/2 000), 0.35%(7/2 000), 0.15%(3/2 000), 0.15%(3/2 000), 2.15%(43/2 000)], and the differences were statistically significant( P<0.05).The first page pass rate[91.55%(1 831/2 000)], filing accuracy rate[92.60%(1 852/2 000)] and coding accuracy rate [92.05%(1 841/2 000)]in the control group were lower than those in the study group[ 97.75%(1 955/2 000), 98.05%(1 961/2 000), 98.15%(1 963/2 000)], and the differences were statistically significant ( P<0.05). Conclusions:The application of fishbone diagram, Plato and PDCA cycle analysis in medical record management can improve the quality of medical records, shorten the time of medical record arrangement and reduce the rate of medical record defects.