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目的观察行政措施对病案质量监控制度落实的促进作用。方法通过一系列行政措施,保障四级病案质控制度落实。结果前后共抽查8418份病案,比较前后时段的问题病案比率、差错频数、差错构成比。采取措施前后问题病案比率由29.99%(1080份/3682份)下降到25.76%(1220份/4736份)。每份差错病案问题频数由1.99下降到1.34。责任心问题所致问题频数由0.95下降到0.83。能力问题所致问题频数由0.98下降到0.51。病案差错构成比较中,责任心问题比率由62.04%下降到50.84%;能力问题比率则由37.96%上升到49.16%。卡方检验χ2=47.36,P<0.005,双侧。结论行政措施促进了病案质量制度的落实,能帮助改善病案质量。
Objective To observe the promotion effect of administrative measures on the implementation of medical record quality control system. Methods Through a series of administrative measures, we can guarantee the implementation of quality control system for Grade 4 medical records. Results before and after a total of 8418 medical records, comparing the time before and after the medical record ratio, error frequency, error ratio. The rate of medical record before and after the measure was reduced from 29.99% (1080 copies / 3682 copies) to 25.76% (1220 copies / 4736 copies). The frequency of each medical record dropped from 1.99 to 1.34. The frequency of problems caused by the responsibility problem decreased from 0.95 to 0.83. The frequency of problems caused by capacity problems decreased from 0.98 to 0.51. Among the constitutional errors, the ratio of responsibility problems dropped from 62.04% to 50.84%, while that of capacity problems increased from 37.96% to 49.16%. Chi-square test χ2 = 47.36, P <0.005, bilateral. Conclusion Administrative measures promote the implementation of medical record quality system and can help to improve the quality of medical record.