摘要
目的探讨提升住院病案质量的有效方法。方法通过对某院2013年-2014年终末病案的质量检查登记结果,依照评价标准赋质控分,计算出科室平均每份病案的质控分,进行总体比较和分组比较。分组为手术操作科室与非手术操作科室,并按病案首页、出院记录等7项分项比较;并从应扣分值较高的前10位科室中统计主要分值项的问题进行分析。结果 2014年改进质控方法后,全院病案质量明显提升,由2013年的平均一份病案的1.89的应扣分值降为1.57,差异显著,P<0.001。其中非手术操作科室的病案质量提升显著,由2013年的平均一份病案1.8755的应扣分值降为1.3882,差异显著,P<0.028。手术操作科室的病案质量在首程和其他记录上有显著性提高,P<0.0135和P<0.0382。非手术操作科室的病案质量的提高尤其表现在日常病程上,P<0.0089。结论通过终末质控,查找病案缺陷的根本原因,针对原因、加强对临床医师的培训,并结合动态的环节质控及改变质控工作的习惯,使住院病案质量有效提升。适当扩大精细化质控的范围,使病案质量持续改进。
Objective To explore effective ways to improve the quality of terminal medical records through practice. Methods To give quality control score to every registration results of terminal medical records examination from 2013 to 2014 of a hospital, figure out the average quality control score that should be of each medical record of each department. To divide into department of surgery and pure department of internal medicine from overall aspect and grouping aspect by the comparison results of 2013 and 2014, then made comparison on 7 items such as front pages of medical records, discharge records and so on. As well as conducted analysis and description on the main detail problems from the top ten clinical departments of score losing. Results After improving quality control, overall quality of medical record improved obviously. Average quality control score that should be of each medical record down to 1.57 from 1.89 in 2013, the significant difference, P〈0.001.Quality of medical record of pure department of internal medicine improved obviously. Average quality control score that should be of each medical record down to 1.3882 from 1.8755 in 2013, the significant difference, P〈0.028. Quality of medical record of surgery improved obviously main from the first course of disease and the other record, P〈0.0135 and P〈0.0382.Quality of medical record of pure department of internal medicine improved obviously, especially in daily course P〈0.0089. Conclusions By the implementation of quality control of terminal medical records, we found out the root reason of medical record defects, aimed at these reasons, we should strengthen the training of clinicians, combined with dynamic link quality control and changes in the habit of quality control such as how to make quality control method more intensive and improve the quality of inpatient medical records. Aimed at the problems still existing, we should keep attaching importance on the key points and enlarge the extent of elaborate quality control, so as to realize continual quality improvement of medical records.
出处
《中国病案》
2016年第7期14-17,共4页
Chinese Medical Record
基金
新疆医科大学人文社会科学基金(2014XYDSK11)
关键词
住院病案
监控
持续改进
Hospitalization medical records
Monitoring
Continual improvement
