内蒙古自治区三级综合医院病案质量评价与分析  

Evaluation and Analysis on the Medical Records Quality of the Class-A and Tertiary Comprehensive Hospital in Inner Mongolia Autonomous Region

作　　者：张丽敏[1,2] 杨建玲[3] 彭向东[3] 曲大鹏[3] 王海明[3] 李晶[3] 焦素英[3] 白瑞敏[3] 

机构地区：[1]内蒙古自治区病案质控中心 [2]赤峰学院第一临床部 [3]赤峰学院附属医院医务部,内蒙古赤峰市024000

出　　处：《中国病案》2013年第12期17-19,共3页Chinese Medical Record

摘　　要：目的通过病历评比与检查,初步了解内蒙古自治区病历质量的现状,总结分析存在的问题,为今后病历质量的控制提供方向。方法对全区25家三级综合医院随机抽取250份病历,其中死亡病历50份,外科乙类以上手术100份,内科疑难危重病历100份。由医疗相关专业专家10人对抽取的十个专业病历质量进行评价,管理专家进行审核。结果甲级病历138份,占55.2%;乙级病历108份,占43.2%;丙级病历4份,占1.6%。结论甲级病历率较低,总体病历书写水平不能令人满意,因此,就存在的质量缺陷进行总结分析,提出整改措施,持续提高全区病历质量。Objective To conduct a preliminary investigation on the current situation of medical records quality in Inner Mongolia Autonomous Region and summarize the existing problems according to the appraisal and review of the medical records, and provide direc- tion for the fi^rther quality control of the medical records. Methods 250 cases of medical records was checked randomly from 25 Class-A and tertiary comprehensive hospital, in which we found there were 50 cases of dead medical records, 100 cases of surgical operation of more than class B and 100 cases of internal medicine intractable or critical medical records respectively. Then conduct quality evaluation on 10 cases of professional medical records by l0 related professional experts, and examine by management experts. Results 138 medical records are class A, accounting for 55.2%, 108 medical records are class B, accounting for 43.2%, 4 medical records are class C, ac- counting for 1.6%. Conclusions The rate of class A medical records was low, the overall writing quality of medical records was not satisfactory. Therefore, we conduct summarize and analysis on the existing quality deficiency, put forward rectify measures and improve the quality of medical records of the whole district continuously.

关 键 词：内蒙古 病历质量 缺陷 分析 

分 类 号：R197.3[医药卫生—卫生事业管理]