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目的通过将出院病案存在的问题进行反馈并及时整改,不断提高出院病案质量。方法对2012年1月-6月出院病案质量进行分析并予以反馈,与2013年1月-6月出院病案质量进行比较分析。结果缺陷病历发生率由25.68%下降至14.15%,缺陷病历的缺陷项目频次由5433次下降至2076次,呈显著降低。甲级病案发生率由90%提升至94.6%,杜绝了丙级病历。结论将既往出院病案存在的问题予以反馈,能有效地提高后期出院病案质量,是一种科学、有效的管理方法。
Objective To improve the quality of discharged medical records by feeding back the problems existing in discharged medical records and timely rectifying them. Methods The quality of discharged medical records from January to June in 2012 was analyzed and feedbacked, and the quality of discharged medical records in January to June in 2013 was compared and analyzed. Results The incidence rate of defective medical records decreased from 25.68% to 14.15%. The frequency of defective medical records decreased from 5433 to 2076, which was significantly lower. Grade A case rate increased from 90% to 94.6%, to eliminate the Class C medical records. Conclusion It is a scientific and effective management method to feedback the existing problems of discharged medical records and improve the quality of discharged medical records in the later period.