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目的通过对全面质量监控实施前后病案的比较,了解病历缺陷的分布和原因,分析实施病历全面质量监控对终末病历质量的影响,探讨提高终末病历质量的措施。方法采用随机分层抽样方法,抽取全面质量监控实施前后各1260份病案进行分析,比较两组病案平均住院病案评分、病案缺陷频次、病案缺陷率和甲级病案率。结果在实施全面质量监控后,平均住院病案评分的分值由94.1分提高到96.3分,甲级病案率由全面质量监控前的93.5%上升至98.4%,平均住院病案评分和甲级病案率均有显著提高(P<0.05);平均每份病案缺陷频次由监控前的7.8频次下降至监控后的2.7频次,病案缺陷率则由全面质量监控前的46.8%下降至监控后18.3%,平均病案缺陷频次和病案缺陷率均有显著下降(P<0.05)。结论在医院管理过程中,实施全面质量监控,加强运行病历环节质量检查,完善病案质量的信息反馈体系,可有效提高住院病案评分和医院的甲级病案率,减少病案缺陷,降低病案缺陷率,以达到提高终末病案质量的目的。?
Objective To understand the distribution and causes of medical records defects by comparing the medical records before and after the implementation of Total Quality Control (GQC), analyze the impact of implementing total quality control of medical records on the quality of final medical records, and discuss the measures to improve the quality of final medical records. Methods Random stratified sampling was used to analyze 1260 cases before and after the implementation of total quality control. The average inpatient medical record, the frequency of medical record defects, the rate of medical record defects and the grade A case were compared between the two groups. Results After implementing total quality control, the average score of inpatient medical records increased from 94.1 to 96.3. The grade A medical record rate rose from 93.5% before the total quality control to 98.4%. The average inpatient medical record and Grade A medical record were all (P <0.05). On average, the frequency of each medical record defect decreased from 7.8 before monitoring to 2.7 after monitoring. The rate of medical record defect decreased from 46.8% before the total quality control to 18.3% after the monitoring. The average medical record The frequency of defects and the rate of medical record defects decreased significantly (P <0.05). Conclusion In the process of hospital management, the implementation of total quality control, strengthening the quality inspection of medical record links and improving the information quality of medical records can effectively improve the inpatient medical record and Grade A medical record in hospital, reduce the medical record defects, reduce the medical record defect rate, In order to achieve the purpose of improving the quality of the final medical record. ?