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目的探讨提升住院病案质量的有效方法。方法通过对某院2013年-2014年终末病案的质量检查登记结果,依照评价标准赋质控分,计算出科室平均每份病案的质控分,进行总体比较和分组比较。分组为手术操作科室与非手术操作科室,并按病案首页、出院记录等7项分项比较;并从应扣分值较高的前10位科室中统计主要分值项的问题进行分析。结果 2014年改进质控方法后,全院病案质量明显提升,由2013年的平均一份病案的1.89的应扣分值降为1.57,差异显著,P<0.001。其中非手术操作科室的病案质量提升显著,由2013年的平均一份病案1.8755的应扣分值降为1.3882,差异显著,P<0.028。手术操作科室的病案质量在首程和其他记录上有显著性提高,P<0.0135和P<0.0382。非手术操作科室的病案质量的提高尤其表现在日常病程上,P<0.0089。结论通过终末质控,查找病案缺陷的根本原因,针对原因、加强对临床医师的培训,并结合动态的环节质控及改变质控工作的习惯,使住院病案质量有效提升。适当扩大精细化质控的范围,使病案质量持续改进。
Objective To explore an effective way to improve the quality of inpatient medical records. Methods According to the registration results of the quality check of the final medical records of a hospital from 2013 to 2014 and according to the evaluation criteria of quality control, the average quality control points of each department were calculated, and the overall comparison and group comparison were made. Divided into surgical departments and non-surgical departments, and according to the first page of medical records, discharge records and other seven sub-items to compare; and from the top 10 departments should be deducted the statistics of the main points of the problem analysis. Results After improving the quality control method in 2014, the quality of medical records in the hospital increased significantly from 1.87 in 2013 to 1.57. The difference was significant (P <0.001). Among them, the quality of medical records in non-surgical departments increased significantly from 1.8082 to 1.3882, which was an average of 1.8755 in 2013. The difference was significant (P <0.028). The quality of medical records in the surgical departments was significantly improved on the first pass and other records, P <0.0135 and P <0.0382. Improvements in the quality of medical records in non-surgical departments are particularly evident in the daily course, P <0.0089. Conclusions The quality of inpatient medical records is effectively improved by finding out the root causes of medical record defects through end-of-life quality control, aiming at the reasons, strengthening the training of clinicians, combining the dynamic quality control and changing the habit of quality control work. Appropriately expand the scope of quality control so that the quality of medical records will be continuously improved.