【摘要】 目的 探究基于计划（Plan）-执行（Do）-研究（Study）-处理（Act）循环的规范化管理在医院病案管理中的应用效果。方法 选取2023年6—12月上海市第一人民医院酒泉医院病案室14名工作人员及同期5 000份病案作为传统组，采用传统病案管理模式；2024年1—6月将同一批工作人员及同期5 000份病案作为研究组，实施基于PDSA的规范化病案管理。比较两组病案管理质量、病案管理效率及病案相关差错率。结果 研究组病案管理质量总分为（93.63±4.25）分，病案管理效率总分为（93.38±3.96）分，均高于传统组的（89.45±5.17）分、（89.29±4.83）分，差异均有统计学意义（t=44.164,2.450;P均<0.05）。研究组病案相关差错率低于传统组，差异有统计学意义（P<0.05）。结论 基于PDSA的规范化管理可提升医院病案管理质量与管理效率，降低病案差错率。更多还原

【Abstract】 Objective To explore the application effect of the standardized management based on the cycle of PlanDo-Study-Act in hospital medical record management. Methods Fourteen staff members from the medical record room of Shanghai First People’s Hospital Jiuquan Hospital from June to December 2023 and 5 000 medical records during the same period were selected as the traditional group, and the traditional medical record management mode was adopted. From January to June 2024, the same batch of staff and 5 000 medical records during the same period were taken as the study group to implement a standardized medical record management based on PDSA. Compared the quality of medical record management, the efficiency of medical record management and the error rate related to medical records between the two groups. Results The total score of medical record management quality in the study group was 93.63±4.25, and the total score of medical record management efficiency was 93.38±3.96, which were higher than those in the traditional group 89.45±5.17 and 89.29±4.83, and the differences were statistically significant(t=44.164, 2.450; both P<0.05). The error rate related to medical records in the study group was lower than that in the traditional group, and the difference was statistically significant(P<0.05). Conclusion Standardized management based on PDSA can improve the quality and efficiency of hospital medical record management and reduce the error rate of medical records.更多还原