摘要
目的探讨住院病案首页实施品管圈的管理效果,并分析其对信息合格率、缺陷情况、团队精神、沟通协调能力、解决问题能力的影响。方法选择某院2024年1月1日—2024年6月31日实施品管圈管理后的20185份住院病案首页作为活动后组,选择2023年7月1日—2023年12月31日实施品管圈管理前的18500份住院病案首页作为活动前组。干预前后均由8位临床医师负责,且干预过程中未出现人员变动。对比品管圈活动实施前后住院病案首页合格率、目标达标率、缺陷发生情况、病案提交及归档时间、圈员临床能力。结果活动后住院病案首页信息合格率97.82%,高于活动前的84.52%(χ^(2)=2186.339,P<0.05),目标达标率125.24%。活动后住院病案首页基本信息漏填0.21%、诊断编码错填0.43%、填写不完整0.86%、病例分型错选0.30%、疾病/手术编码错填缺陷率0.75%及整体缺陷率2.55%,均低于活动前的0.85%、1.25%、2.69%、1.90%、3.21%、9.91%(χ^(2)=76.739、81.173、189.818、234.111、308.321、916.354,P<0.05)。活动后病案平均提交(2.47±0.19)天、归档时间(2.95±0.24)天,均短于活动前的(7.15±0.34)天、(7.86±1.31)天(t=1688.929、523.016,P<0.05)。结论品管圈实施可有效提高住院病案首页信息合格率,降低基本信息漏填、诊断编码错填、填写不完整、病例分型错选、疾病/手术编码错填等缺陷事件发生率,缩短病案平均提交及归档时间,同时还可以提高圈员积极主动性、沟通协调能力等临床能力,保障患者诊治安全。
Objectives This study aims to explore the effect of implementing a quality control circle on the front page of inpatient medical records,and analyze its impact on information qualification rate,defect situation,team spirit,communication and coordination ability,and problem-solving ability.Methods A total of 20,185 inpatient medical record front pages after the implementation of quality control circle management in a certain hospital from January 1,2024 to June 31,2024 were selected as the post-activity group,and 18,500 inpatient medical record front pages before the implementation of quality control circle management from July 1,2023 to December 31,2023 were selected as the pre-activity group.The qualification rate of the inpatient medical record front page,the target achievement rate,the occurrence of defects,the submission and filing time of medical records,and the clinical ability of circle members were compared before and after the implementation of the quality control circle activities.Results The qualification rate of the front-page information of hospitalization medical records after the activity was 97.82%,which was higher than 84.52%before the activity(χ^(2)=2186.339,P<0.05),and the target achievement rate was 125.24%.After the activity,the basic information on the front page of hospitalization medical records was missing by 0.21%,the diagnostic code was incorrectly filled in by 0.43%,the incomplete filling was 0.86%,the case classification was incorrectly selected by 0.30%,the defect rate of disease/surgery code was 0.75%,and the overall defect rate was 2.55%,all of which were lower than before the activity(0.85%,1.25%,2.69%,1.90%,3.21%,9.91%)(χ^(2)=76.739,81.173,189.818,234.111,308.321,916.354,P<0.05).The average submission time and filing time of medical records after the activity were 2.47±0.19 days and 2.95±0.24 days,respectively,which were shorter than those before the activity(7.15±0.34 and 7.86±1.31 days;t=1688.929,523.016,P<0.05).Conclusions The implementation of quality control circles can effectively improve the qualification rate of information on the front page of inpatient medical records,reduce the incidence of defects such as missing basic information,incorrect diagnosis codes,incomplete filling,wrong case classification,incorrect disease/surgery codes,etc.,shorten the average submission and archiving time of medical records,and at the same time improve the clinical abilities of circle members such as initiative,communication and coordination skills,to ensure the safety of patient diagnosis and treatment.
作者
黄竹
Huang Zhu(Fuyang Hospital Affiliated to Anhui Medical University,Fuyang City 236000,Anhui Province,China)
出处
《中国病案》
2025年第5期15-18,共4页
Chinese Medical Record
关键词
住院病案首页
品管圈
信息合格率
缺陷
Inpatient medical record front page
Quality control circle
Information qualification rate
Defects
Team spirit
Communication and coordination skills
Problem solving ability
