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目的了解目前病案质控人员的实际质控水平,为今后病案质控人员的培训工作提供依据。方法由出题专家按照原卫生部《病案书写基本规范》编写存在常见书写缺陷的临床病案,作为测试的考题,同时出具标准答案。参加测试的病案质控人员在规定的时间内进行闭卷答题。试卷由经过培训的病案质控专家统一批阅,100分为满分,60分为及格。按照医院类别、医师类别、试题类别的得分情况进行汇总。结果参考人数240人,平均分59.60分,及格率55.42%。测试成绩二级甲等以上医院的质控人员水平相对较高,三级甲等医院的及格率为68.79%,三级医院及格率为73.53%,二级甲等医院及格率为62.07%,二级及其它医院的成绩相对较低,及格率为35.56%。首页部分得分率最高,为76.73%,出院小结部分得分率最低,为37.71%。临床医师的考试成绩高于非临床医师的考试成绩,前者的及格率为80.74%,后者的及格率为22.86%。结论病案质控人员的质控水平需要进一步的提高,尤其是二级以下医院的病案质控人员的质控水平需要大幅提高;临床医师的病案质控水平较高,病案终末质控应首选临床医师来承担。病案质控人员在质控中的薄弱环节是术前小结、术前讨论、手术记录、出院小结,有待进一步的加强。
Objective To understand the actual quality control of medical record staff and to provide the basis for future training of medical record staff. Methods According to the original title of the Ministry of Health, “writing the basic norms of medical records writing,” write a clinical case of common writing defects, as a test questions, at the same time issued a standard answer. Participate in the test case quality control staff within the prescribed time closed-book answer. Paper by the training of medical record quality control experts unified review, 100 points for the perfect score, 60 points for the pass. According to the hospital category, the type of physician, test questions category summary. The results refer to the number of 240 people, with an average of 59.60 points, the pass rate of 55.42%. The test scores were higher than the first two hospitals above the level of quality control staff level, three first-class hospitals pass rate of 68.79%, three hospitals 73.53% pass rate, two pass rate of 62.07% of hospitals, Grade and other hospitals have relatively low grades with a pass rate of 35.56%. Home part of the highest scoring rate was 76.73%, discharged part of the summary score the lowest rate of 37.71%. Clinic examination results than non-clinicians test scores, the former’s pass rate was 80.74%, the latter’s pass rate was 22.86%. Conclusion The quality control of medical record staff needs to be further improved. In particular, the quality control of medical record staff in hospitals below secondary level 2 needs to be improved significantly. Clinicians’ Clinician to bear. Quality control personnel in the quality control of the weak link is the preoperative summary, preoperative discussion, surgical records, discharge summary, pending further strengthening.