摘要
目的通过对归档病案质控检查,分析存在的问题及原因,制定相应的对策,提高病历书写质量。方法随机抽查某院2017年1月1日-2017年12月31日期间1746份归档病案,每月中旬随机抽取每位住院医师2份住院天数在14天以上的首选有手术或操作的上月出院病案,抽查量约占月出院病案的7%~8%。组织专家根据医院《住院病案质量评价用表》评分,通过Excel2016版本汇总数据,描述性统计分析存在的问题缺陷,提出整改措施。结果1746份病案中,共有4946项缺陷,平均每份病案有2.83项缺陷,甲级病案率为99.48%,乙级病案率为0.52%;住院病案首页、入院记录、病程记录、知情同意书、其他方面总缺陷次数分别为439、1391、2322、249、545;内科、外科、妇产科和儿科平均每份病案缺陷数分别为3.14、2.71、2.46和2.46。结论完善医疗质量管理组织体系,加大培训力度,加强关键环节质控管理,持续改进病案内涵书写质量、环节质控等方式持续改进病历书写质量,降低医疗隐患,保障医疗安全。
Objective To improve the quality of medical record writing by analyzing the existing problems and causes through quality control examination of archived medical records.Methods 1746 archived medical records were randomly selected from January 1,2017 to December 31,2017 in our hospital.In the middle of each month,2 discharged medical records of each resident with more than 14 days of hospitalization were randomly selected.The first choice was the medical records with surgery or operation.The monthly sampling amount accounted for about 7%~8% of the monthly discharged medical records.According to the quality evaluation form of inpatient medical records,Experts were organized to scored them,summarized the data by Excel 2016 version,and analyzed the existing problems and defects by descriptive statistical analysis,and the corrective measures were put forward.Results There are 4946 defects in 1746 medical records,with an average of 2.83 defects per medical record.The rate of grade A medical records was 99.48%.The rate of grade B medical records was 0.52%.The total number of defects in the first page of medical records,admission records,course records,informed consent and other aspects were 439,1391,2322,249 and 545 respectively;The average number of defects per medical record of internal medicine,surgery,obstetrics and Gynecology and pediatrics were 3.14,2.71,2.46 and 2.46 respectively.Through improving the organization system of medical quality management,increasing the training intensity,improving the consciousness of all members,focusing on the quality control of the medical records and so on,the quality of medical records can be improved continuously and the hidden danger of medical treatment is reduced.Conclusion The quality of medical records is one of the important contents of hospital quality and safety management.Our hospital will continue to strengthen the training and quality control of medical records through PDCA cycle,strengthen the key link quality control management,and continuously improve the quality of medical record connotation writing to ensure medical safety.
作者
陶然
兰峻斌
李星
李雯雯
艾朝雄
Tao Ran;Lan Junbin;Li Xing;Li Wenwen;Ai Chaoxiong(Xiamen Haicang Hospital,Xiamen 361026,Fujian Province,China;不详)
出处
《中国病案》
2021年第12期16-19,共4页
Chinese Medical Record
关键词
归档病案
质控
持续改进
病案质量
Archiving medical records
Quality Control
Continuous improvement
Quality of medical records
