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为了解JCI标准下对病案质量评价的要求与我国医院普遍所采用的病案质量评价标准存在的差异和共同点;通过比较分析两种标准下的评价工具和评价结果表达、评价专家的资质要求、评价内容;发现国内采用的《住院病历质量评价用表》与JCI所采用的《医疗记录审查工具》在设计结构和结果表达上有所差异,前者用分数衡量质量,后者用标准符合率衡量;在评价专家上后者不仅要求医护人员参与评价,还要求营养师、康复师等参与评价;在评价内容上后者比前者更重视医疗记录的完整性,突出强调患者的疼痛评估、患者权利与教育、就医连续性照护、及其他个性化评估;藉此为病案质量评价的进一步优化和医疗行为的改善提供了可以相互借鉴的思路和建议。
In order to understand the differences and commonalities between the medical records quality evaluation requirements under the JCI standard and the commonly used medical records quality evaluation standards in our hospitals, the paper evaluates the qualifications of the experts through comparative analysis of the evaluation tools and evaluation results under the two standards, Evaluation content; found that the domestic use of “hospital health record quality evaluation table” and the JCI “Medical Records Review Tool” in the design structure and the results of the expression differences, the former using the score to measure the quality, the latter with the standard compliance rate ; Evaluation experts who not only require the medical staff to participate in the evaluation, but also require dietitians, rehabilitation workers, etc. involved in the evaluation; the latter on the evaluation of the latter more emphasis on the integrity of the medical records, highlighting the patient’s pain assessment, patient rights And education, continuous medical care, and other personalized assessments; thus providing ideas and suggestions for further evaluation of medical record quality and improvement of medical practice.