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目的分析并改进基于医疗质量与安全考核系统的病案质量管理方法。方法我院病案科于2015年1月开展病案质量管理,主要基于医疗质量与安全考核系统,于实施前(2014年1-12月)及实施后(2015年1-12月)分别抽取病案1000份,比较实施前后终末病案甲级率及返修率。结果实施后病案返修率为1.5%,低于实施前12.1%(P<0.05);实施后病案甲级率为98.5%,高于实施前87.9%(P<0.05)。结论基于医疗质量与安全考核系统的病案质量管理可明显提升病案管理质量,值得推广。
Objective To analyze and improve medical record quality management methods based on medical quality and safety assessment system. Methods The medical records management system was conducted in January 2015 in our hospital based on the medical quality and safety assessment system. Before the implementation (January-December 2014) and after implementation (January-December 2015), the medical records were drawn from 1000 Copies, before and after the implementation of the final case record A rate and repair rate. Results After the implementation, the rate of return was 1.5%, which was lower than 12.1% before implementation (P <0.05). After the implementation, the first grade rate was 98.5%, which was higher than that before implementation (87.9%, P <0.05). Conclusion The medical record quality management system based on medical quality and safety assessment system can significantly improve the quality of medical record management and is worth promoting.