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

DOI: 10.12201/bmr.202409.00064

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  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

  Submit time: 29 September 2024

  Copyright: The copyright holder for this preprint is the author/funder, who has granted biomedRxiv a license to display the preprint in perpetuity.
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