摘要
目的对医护一体化运行病历管理在泌尿外科中的效果实施深入性探析。方法选取2018年1月—2020年1月在重庆市开州区人民医院泌尿外科工作的28名医护人员为研究对象,2018年1月—2019年1月实施常规性的病历管理措施,2019年2月—2020年1月实施医护一体化运行病历管理措施,对实施管理前后医护人员的各项患者病历指标评分、医护人员考核总合格率情况、病历差错概率以及医护人员对病历管理模式的满意程度进行比较。结果实施前医护人员的各项患者病历指标评分、考核总合格率均低于实施后,差异有统计学意义(P<0.05)。实施前患者发生病历差错的概率高于实施后,差异有统计学意义(P<0.05)。实施前医护人员对病历管理模式的满意程度低于实施后,差异有统计学意义(P<0.05)。结论在泌尿外科中实施医护一体化运行病历管理模式可以显著提升运行病历质量,推动医患之间的沟通,显著降低病历差错概率,提升医护人员对病历管理模式的满意程度。
Objective To conduct an in-depth analysis of the effect of integrated medical records management in urol-ogy.Methods 28 medical and nursing staff working in the Urology of Kaizhou District People's Hospital of Chongqing from January 2018 to January 2020 were selected as the research objects.Routine medical record management mea-sures were implemented from January 2018 to January 2019,and medical and nursing integrated operation medical re-cord management measures were implemented from February 2019 to January 2020.The patient case index scores of medical and nursing staff before and after the implementation of management,the overall qualification rate of medical and nursing staff assessment,the incidence of case errors and the satisfaction level of medical staff with the medical record management model before and after the implementation of management were compared.Results The scores of various patient case indicators and the overall pass rate of assessment for medical staff before the implementation were lower than those after the implementation,the difference was statistically significant(P<0.05).The probability of pa-tients making case errors before implementation was higher than that after implementation,and the difference was sta-tistically significant(P<0.05).The satisfaction level of medical staff with the medical record management model before the implementation was lower than that after the implementation,and the difference was statistically significant(P<0.05).Conclusion The implementation of medical and nursing integrated operation medical record management mode in Urology can significantly improve the quality of operation medical record,promote the communication between doc-tors and patients,significantly reduce the probability of case errors,and improve the satisfaction of medical personnel with the medical record management mode.
作者
王明川
廖敏
张立冬
李永前
WANGMingchuan;LIAOMin;ZHANGLidong;LIYongqian(Department of Urology,Kaizhou District People's Hospital,Chongqing,401400 China)
出处
《中国卫生产业》
2023年第8期97-100,共4页
China Health Industry
关键词
医护一体化
病历管理
泌尿外科
满意度
合格率
差错发生率
Medical and nursing integration
Medical record management
Urology
Satisfaction degree
Pass rate
Error incidence rate
