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目的研究全方位加强科室病案质量控制对我院肾内科终末病历质量的影响。方法选取2013年我院肾内科终末病历2547份作为实验组,2012年终末病历2373份为对照组,实验组全方位加强科室质量控制,对照组实行常规质量控制,比较两组病历缺陷数、平均住院病历评分值及甲级病历率;结果实验组住院病历缺陷数明显低于对照组,平均住院病历评分值及甲级病历率明显高于对照组,差异有统计学意义。结论全方位加强科室病案质量控制可有效提高我院肾内科终末病历质量,值得推广应用。
Objective To study the impact of quality control of medical records in all directions on the quality of final medical records of nephrology in our hospital. Methods Totally 2547 cases of end-stage renal disease in our hospital were selected as the experimental group in 2013 and 2373 cases in the end of 2012 as the control group. The experimental group strengthened quality control in all departments and the control group received routine quality control. The average hospitalization medical record score and Grade A medical records; Results The number of hospitalized medical records in the experimental group was significantly lower than the control group, the average hospital medical record score and Grade A medical records were significantly higher than the control group, the difference was statistically significant. Conclusion It is worth to popularize the application of improving the medical records quality of department in all respects to improve the quality of final medical records of nephrology in our hospital.