实施临床路径对终末病历病案质量的影响  

The Influence of Clinical Pathway on Terminal Medical Record Quality

作　　者：马国胜[1] 蔡曦光[1] 张东[1] 孟永洁[1] 陈红纲[1] 刘晓霞[1] 包雅琴 

机构地区：[1]甘肃省人民医院质控处,兰州市730000

出　　处：《中国病案》2013年第5期30-32,共3页Chinese Medical Record

基　　金：甘肃省卫生行业科研计划管理项目(GWGL2011-5)

摘　　要：目的通过对终末病历病案质量的评价分析,研究实施临床路径对病历病案质量影响。方法选择2010年8月至2012年8月实施临床路径管理的病例1436例作为观察组,随机选择同时期未实施临床路径的病例1430例作为对照组。所有病历均经病历质量专家小组评审并确定甲级、乙级、丙级;记录"单项否决项"和"单项扣分5分"的病历数及核查出院病历3日归档率、病案首页完整规范率和病历完整性。结果观察组终末病历的甲级率比对照组明显提高,乙级和丙级率比对照组明显降低(P<0.001);观察组"单项否决"和"单项扣分5分"的发生率低于对照组(P<0.05);观察组出院病历3日归档率、病案首页填写完整规范率和病历完整性高于对照组(P<0.05)。结论实施临床路径不仅对提高医疗质量和保障医疗安全有重要作用,而且有助于提高病案质量和完善病案管理。Objective To study the effect of the implementation of chnical pathway on quality of medical records through evaluating and analyzing quality of terminal medical records. Methods A total of 1436 patients who were treated by clinical path procedure, were selected as observation group from August 2010 to August 2012. A total of 1430 cases without introducing clinical pathway at the same time were randomly selected as the control group. According to regulations of the Ministry of Health, all medical records were reviewed by the experts, and three grades of A, B and C were determined; recording the ＂line item veto＂ and ＂individually subtracting 5 points＂ ; inspecting filing rate of discharged within three days, completing standard of the front page of medical records , and the integrity of medical records. Results The rates of grade A in the observation group were much stronger than that of control group, while the rates of grade B and C were significantly lower than those of control group （ P 〈 0. 001 ） ; ＂ The hne item veto＂ and ＂the individually subtracting 5 points ＂ in observation group were lower than those of the control group （ P 〈 0.05 ） ; The filing rates of discharged medical records within three days, completing standard to the front page of medical records and the integrity of medical records in the observation group were higher than that of the control group （ P 〈 0.05）. Conclusion The clinical pathway plays not only a important role in improving the medical quality and in medical safety, but also there are helps for improving the quality of medical records and raising the management of medical record.

关 键 词：临床路径 终末病历 病案质量 

分 类 号：R197.3[医药卫生—卫生事业管理]