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目的我院自2006年起开始实施运行病历质量监控,通过比较2006年前后三年的终末病案质量指标,分析实施运行病历质量监控对终末病案质量的影响。方法随机抽取病案,专家分组,根据《中山大学住院运行病历评价标准》对环节病历进行评分,计算合格率,提取终末甲级病案率、病案回收率、病案缺陷率等统计数据,采用SPSS13.0统计软件进行分析。结果 2006年前后三年各科室的平均终末甲级病案率、病案缺陷率、病案回收率的差值有统计学意义;2006～2008年终末甲级病案率、病案回收率呈逐年递增曲线,并且与同期环节病历合格率递增趋势一致。结论实施运行病历质量监控对终末病案质量的提高有促进作用。
Objective Since 2006, our hospital began to implement the monitoring of medical record quality. By comparing the final medical record quality indicators in three years before and after 2006, we analyzed the impact of running quality records on the quality of final medical records. Methods The medical records and experts were randomly divided into groups and scored according to the “Medical Record of Sun Yat-sen University Hospital Operation Record” to calculate the pass rate and extract the statistics of the final grade A case, the recovery rate of the medical record and the defect rate of the medical record. SPSS13 was used. 0 statistical software for analysis. Results The average final grade A case rate, the rate of medical record defect and the recovery rate of medical records in all the departments before and after the three years of 2006 were statistically significant. From the end of 2006 to 2008, the grade A case and the rate of recovery of the medical record showed an increasing curve year by year, And with the same period the medical records pass rate increasing trend consistent. Conclusion The implementation of medical record quality control can improve the quality of the final medical record.