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目的探讨临床医师病案室轮转制度对病案质量的影响。方法对医师进行培训、考核并督导其完成量化的轮转工作,比较此制度实施前后的考核指标。结果轮转制度实施后病案质量评分(85.62.vs.95.17,P<0.001)、病案知识评分(81.09.vs.93.63,P<0.001)及病案法律法规知晓率(80.60%.vs.97.01%,P<0.01)均显著性提高,病案缺陷率(32.84%.vs.21.39%,P<0.05)及返修率(37.81%.vs.16.92%,P<0.001)均显著性降低。结论病案室轮转制度增强了医师的病案质量及法律意识,有利于提高病案内涵质量。
Objective To explore the impact of clinicians’ case rotation system on the quality of medical records. Methods The physicians were trained, evaluated and supervised to complete the quantitative rotation work. The assessment indexes before and after the implementation of this system were compared. Results After the implementation of the rotation system, the quality of medical records (85.62.vs.95.17, P <0.001), medical record knowledge scores (81.09.vs.93.63, P <0.001) and the awareness rate of medical records laws and regulations (80.60% vs. 97.01%, P <0.01). The rate of medical record defect (32.84% .vs.21.39%, P <0.05) and rework rate (37.81% .vs.16.92%, P <0.001) decreased significantly. Conclusion The system of case-case rotation enhances physicians’ medical record quality and legal awareness, which helps to improve the quality of medical record connotation.