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目的分析计算机打印病案单项否决项目产生的原因,探讨提高病案质量的有效方法及规范化管理的措施。方法按照卫生部颁布的《病历书写基本规范》、《住院病案首页部分项目填写说明》的具体要求,对2006年1月至2011年12月18460份计算机打印病历进行终末质量控制,利用SPSS17.0统计学软件对单项否决情况进行统计分析。结果手术科室病案甲级率(89.88%)明显低于非手术科室(95.48%)(χ2=189.562,P<0.01),终末病案甲级率的下降有93.8%同单项否决率有关〈^Y(甲级率)=0.995-1.145X(单项否决率),P<0.01〉。丙级病案1199份,丙级率6.5%。结论单项否决项目的缺陷是造成病案质量下降,尤其是丙级病案产生的主要原因。应查找原因,建立有效的管理方法,减少单项否决项目的发生。
Objective To analyze the causes of items rejected by computers in print medical records and discuss the effective ways to improve the quality of medical records and the measures of standardized management. Methods The quality control of 18,460 computerized medical records from January 2006 to December 2011 was carried out according to the requirements of the “Basic Medical Record Writing Standards” and “Fill in Instructions for the First Part of Inpatient Medical Records” issued by the Ministry of Health. SPSS17 was used. 0 statistical software for individual denial of statistical analysis. Results The grade A (89.88%) of surgical departments was significantly lower than that of non-surgical departments (95.48%) (χ2 = 189.562, P <0.01). The decrease of Grade A in final medical records was 93.8% (Grade A) = 0.995-1.145X (single rejection), P <0.01>. Grade C medical record 1199, C rate of 6.5%. Conclusion The defect of the individual veto project is the main reason that causes the quality of medical record to decline, especially Grade C record. Should find out the reasons, establish effective management methods, reduce the occurrence of individual veto projects.