摘要
目的研究分析内科病案质量与外科病案质量存在的问题,并探讨提高病案质量的措施。方法随机选取2017年8月~2018年8月我院内外科病案共4120份纳入研究,并对其质量进行评分,对病案质量中存在的问题进行分析。结果内外科各项质量缺陷分布比较,差异无统计学意义(P>0.05);内科病案质量相比外科病案质量更高,差异有统计学意义(P<0.05)。结论因诊疗流程与疾病特征不同,因而内外科病案质量存在差异,医院需针对内外科病案质量中存在的问题进行针对性管理,提高病案质量。
Objective To study and analyze existing problems in the quality of medical records of the department of internal medicine and the department of surgery and to explore measures to improve the quality of medical records.Methods 4,120 medical records in the department of internal medicine and the department of surgery in our hospital from August 2017 to August 2018 were randomly selected and included in the study.The quality of medical records was scored and existing problems in the quality of medical records were analyzed.Results There was no statistically significant difference in the distribution of quality defects between the department of internal medicine and the department of surgery(P>0.05).Compared with the quality of medical records of the department of surgery,the quality of medical records of the department of surgery was higher.And the difference between the two groups was statistically significant(P<0.05).Conclusion Because of the different diagnosis and treatment processes and disease characteristics,there are differences in the quality of medical records between the department of internal medicine and the department of surgery.The hospitals need carry out targeted management on the problems existing in the quality of medical records of the department of internal medicine and the department of surgery in order to improve the quality of medical records.
作者
许海珊
郭俊延
XU Haishan;GUO Junyan(Medical Record Room,the Second People’s Hospital of Zhanjiang,Zhanjiang 524003,China)
出处
《中国医药科学》
2019年第19期186-188,共3页
China Medicine And Pharmacy
关键词
内外科
病案质量
缺陷
质控
Department of internal medicine and the department of surgery
Quality of medical records
Defects
Quality control
