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目的通过对终末病案质控新增干预措施前后所得质控得分进行对比研究,对干预措施进行评价,为我国病案质控同仁提供参考。方法将实验组和对照组2015年上半年与2016年同期总出院量的增长率进行比较;对每个科室2016年上半年得分与2015年同期终末病案质控得分相减,采用SPSS18.0软件对所得实验组与对照组差值进行方差齐性检验和t检验。结果将2016年上半年与2015年同期终末病案质控平均得分相减,所得两组数据进行方差齐性检验(P=0.313)和t检验(t=2.989),P<0.05,差异有统计学意义。结论将“事后质控”转变为“事前、事中、事后均质控”模式,对临床书写病历人员开展同质化的经常性教育和引导,把质控之脚迈向临床一线,才能更好的提高终末病案的质量。
OBJECTIVE To compare the quality control scores obtained before and after the new interventions for quality control of the final record to evaluate the interventions and provide reference for the quality control colleagues in our country. Methods The experimental group and control group were compared in the first half of 2015 with the growth rate of total discharges in the same period of 2016. The score of each department in the first half of 2016 was subtracted from the quality of the final medical record in the same period of 2015. SPSS18.0 Software for the experimental group and the control group difference homogeneity of variance test and t test. Results The mean score of end-of-year disease record control was subtracted from the first half of 2016 to the end of 2015, and the two groups of data were tested for homogeneity of variance (P = 0.313) and t test (t = 2.989) Significance of learning. Conclusions The “post-quality control” will be changed into a “pre-event, post-event and post-event quality control” mode, which will carry out the homogenous and regular education and guidance on the clinical staff writing medical records, First-line, in order to better improve the quality of the final medical record.