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目的:观察分析实施临床路径过程中病案质量控制的体会。方法:将中山市南朗医院(2015年8月至2016年8月)60例社区获得性肺炎临床路径病案作为本次研究对象,使用简单随机法,将其分为两组,其中一组病案进行病案质量控制(研究组34例),另一组病案未进行病案质量控制(常规组26例)。将两组病案的评分值以及缺陷率进行对比分析。结果:研究组病案的评分值为(95.56±2.57)分,显著高于常规组(90.46±3.75)分,差异具有统计学意义(P<0.05);研究组中,知情同意书缺陷率为2.94%、住院时间缺陷率为8.82%、出院评估缺陷率为5.88%、检查项目缺陷率为5.88%,均显著低于常规组(26.92%、26.92%、34.62%、30.77%),差异具有统计学意义(P<0.05)。结论:将病案质量控制应用于临床路径过程中,可提高临床路径病案的质量,减少不规范现象。
Objective: To observe and analyze the experience of the medical record quality control during the implementation of clinical path. Methods: Sixty patients with community-acquired pneumonia clinical pathology cases from Zhongshan Nanlang Hospital (August 2015 to August 2016) were selected as the study subjects. They were divided into two groups according to a simple randomized method. One group of medical records Quality control of medical records (study group 34 cases), another group of medical records without quality control (routine group of 26 cases). The two groups of medical record score and defect rate comparative analysis. Results: The score of the study group was (95.56 ± 2.57) points, which was significantly higher than that of the conventional group (90.46 ± 3.75), the difference was statistically significant (P <0.05). In the study group, the rate of informed consent was 2.94 %, The rate of hospitalization time was 8.82%, the rate of discharge evaluation was 5.88%, the defect rate of examination items was 5.88%, which was significantly lower than that of the control group (26.92%, 26.92%, 34.62%, 30.77%). The difference was statistically significant Significance (P <0.05). Conclusion: The application of medical record quality control in the clinical pathway can improve the quality of clinical pathological medical records and reduce the non-standardization.