摘要
目的探讨临床医师病案室轮转制度对病案质量的影响。方法对医师进行培训、考核并督导其完成量化的轮转工作,比较此制度实施前后的考核指标。结果轮转制度实施后病案质量评分(85.62.vs.95.17,P<0.001)、病案知识评分(81.09.vs.93.63,P<0.001)及病案法律法规知晓率(80.60%.vs.97.01%,P<0.01)均显著性提高,病案缺陷率(32.84%.vs.21.39%,P<0.05)及返修率(37.81%.vs.16.92%,P<0.001)均显著性降低。结论病案室轮转制度增强了医师的病案质量及法律意识,有利于提高病案内涵质量。
Objective To investigate the impact of rotation rules at the department of medical records for physician on the quality of medical records.Methods Physicians involved in the rotation of the medical record department were accepted training,assessment,and promoted to finish the quantitative rotation.The pre-and post-assessment indexes were analyzed respectively.Results The scores of quality（85.62.vs.95.17,P〈0.001）,knowledge（81.09.vs.93.63,P〈0.001）,and the law realizing level of medical records（80.60%.vs.97.01%,P〈0.01） increased significantly,the rate of defect（32.84%.vs.21.39%,P〈0.05） and rewriting（37.81%.vs.16.92%,P〈0.001） decreased significantly.Conclusion It enhances the consciousness of medical record quality and related laws of physician,and contributes to improve the quality of medical records.
出处
《中国病案》
2011年第4期11-12,共2页
Chinese Medical Record
关键词
病案
质量控制
轮转
Medical records
Quality control
Rotation
