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目的通过加强病案质控结果的反馈,提高终末病案质量。方法比较按常规病案质控流程下的2013年1月-2013年12月质控部门质控的541份出院病案与增加反馈环节的病案质控流程下的2014年1月-2014年12月质控的759份出院病案的甲级率。结果有反馈环节质控的出院病案甲级率为96.44%,无反馈环节质控的出院病案甲级率为89.28%,前者甲级率显著高于后者,差异有统计学意义(P<0.05)。结论通过增加病案质控中的反馈环节,可提高终末病案质量。
Objective To improve the quality of the final medical record by strengthening the feedback of the quality control record. Methods According to the routine medical record quality control process under the control of the quality control department from January 2013 to December 2013 quality control 541 cases of discharge and increase the feedback section of the case record quality control process in January 2014 - December 2014 quality Control of the 759 cases of discharge rate of Grade A cases. Results There were 96.44% of discharged cases with feedback quality control and 89.28% of discharged cases without feedback. The former had a higher grade A rate than the latter (P <0.05) ). Conclusion The quality of the final medical record can be improved by increasing the feedback links in the quality control of the medical record.