摘要
目的 探讨将全方位评审制度应用于精神科病案管理,为提升精神科病案管理管理水平提供新思路。方法 某院精神科2019年9月1日开始实施等级评审制度,将2018年8月1日-2019年8月31日出院病案153份作为对照组,将2019年9月1日-2020年9月31日出院病案161份作为观察组,评估两组病案质量,统计病案缺陷发生率、3日归档率、编码正确率、病案调阅时间、病案复印时间和职能考核情况。结果 对照组甲、乙、丙级病案占比分别为92.16%、5.88%、1.96%;观察组分别为98.14%、1.86%、0%;秩和检验结果显示,观察组整体病案质量高于对照组,差异有统计学意义(P<0.05)。观察组的病案缺陷发生率为5.59%,低于对照组的13.07%,差异有统计学意义(P<0.05)。观察组病案的3日归档率、编码正确率为96.89%、99.38%,高于对照组的90.20%、96.08%,差异有统计学意义(P<0.05)。实施后的病案调阅时间、病案复印时间均明显短于对照组(P<0.05)。观察组病案管理者的理论考核、技术考核及绩效考核的合格率为100.00%、100.00%、96.30%,高于对照组的76.92%、86.54%、80.77%,差异有统计学意义(P<0.05)。结论 将全方位评审制度应用于精神科病案管理中,能有效降低病案缺陷发生率,提升病案质量及3日归档率,且有助于提升管理者管理水平及工作效率。
Objectives To explore the application effect of grade evaluation system in medical records management of psychiatric department so as to provide new idea for improving the management level.Methods The grade evaluation system was implemented in psychiatric department of the hospital from September 1 st,2019 on.The period from August 1 st,2018 to August 31 st,2019 was defined as control group,while the period from September 1 st,2019 to September 31 st,2020 was defined as observation group.The quality of medical records in both groups was evaluated.The incidence of medical records defects,3 d archiving rate,accuracy rate of coding,reading time and copy time of medical records,and vocational assessment were statistically analyzed.Results The proportions of grade A,B and C medical records in control group and observation group were(92.16%,5.88%,1.96%) and(98.14%,1.86%,0%),respectively.The results of rank sum test showed that the overall quality of medical records in observation group was higher than that in control group(P<0.05),incidence of medical records defects was significantly lower than that in control group(5.59% vs 13.07%)(P<0.05),3 d archiving rate and accuracy rate of coding were higher than those in control group(96.89%,99.38% vs 90.20%,96.08%)(P<0.05),reading time and copy time of medical records were significantly shorter than those in control group(P<0.05),qualification rates of theoretical assessment,technical assessment and performance assessment in medical record managers were higher than those in control group(100.00%,100.00%,96.30% vs 76.92%,86.54%,80.77%)(P<0.05).Conclusions The application of grade evaluation system in medical records management of psychiatric department could effectively reduce the incidence of medical records defects,improve quality of medical records and 3 d archiving rate,which was beneficial to improve management level and work efficiency of managers.
作者
王杰
斯亮
迟正锁
吕丽华
李彪
Wang Jie;Si Liang;Chi Zhengsuo;Lv Lihua;Li Biao(Wuhan Mental Health Center,Wuhan 430012,Hubei Province,China;不详)
出处
《中国病案》
2022年第6期18-20,34,共4页
Chinese Medical Record
基金
湖北省卫生健康委员会资助课题(WJ2019M016)。
关键词
精神科
病案管理
等级评审制度
病案质量
Psychiatric department
Medical record management
Grade evaluation system
Medical record quality
