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目的将病案评估结果作为对医生资格、晋升、晋职及能力评价的依据,探讨病案质量持续改进的方法与措施。方法选取2013年1月-6月和7月-11月,即新评价制度推行前后某院所有病案共96 651份,分析内科、外科、专科和全院病案质量是否有改善及不同单项否决项目所占构成比有无改变。结果新评价制度实施后内科、外科、专科和全院的缺陷病案率和单否病案率均显著降低(P<0.01),对单项否决项目所占构成比的影响无统计学意义(P=0.884)。结论新评价制度推行后,通过实施加强病历书写培训;严格落实三级医师责任制;加强环节质量管理;重视终末病案质量分析;完善奖惩制度等方法,使得病案质量显著提高,值得推广。
Objective To evaluate the results of medical records as the basis for evaluation of doctors’ qualification, promotion, promotion and competency, and to explore ways and measures for continuously improving the quality of medical records. Methods From January to June 2013 and July to November 2013, 96 651 medical records of a hospital before and after the implementation of the new evaluation system were selected to analyze whether the quality of the medical records in internal medicine, surgery, specialists and hospitals improved and different items were individually rejected The composition ratio has changed. Results After the implementation of the new evaluation system, the defects of medical, surgical, specialist and hospital were significantly reduced (P <0.01), and the impact on the composition ratio of single negative items was not statistically significant (P = 0.884 ). Conclusion After the implementation of the new evaluation system, the medical records writing and training should be strengthened; the responsibility system of the three levels of doctors should be strictly implemented; the quality management of the links should be strengthened; the quality of the final medical record should be emphasized; the reward and punishment system should be improved.