病案质量控制对肾内科终末病历质量的影响  

Influence of Quality Control on Nephrology Terminals Medical Record Quality

作　　者：贾晓燕[1] 周宏久[1] 陈丽娟[1] 李东敏[1] 

机构地区：[1]广东医学院附属医院病案室,湛江市524001

出　　处：《中国病案》2014年第3期19-21,共3页Chinese Medical Record

摘　　要：目的研究全方位加强科室病案质量控制对我院肾内科终末病历质量的影响。方法选取2013年我院肾内科终末病历2547份作为实验组,2012年终末病历2373份为对照组,实验组全方位加强科室质量控制,对照组实行常规质量控制,比较两组病历缺陷数、平均住院病历评分值及甲级病历率;结果实验组住院病历缺陷数明显低于对照组,平均住院病历评分值及甲级病历率明显高于对照组,差异有统计学意义。结论全方位加强科室病案质量控制可有效提高我院肾内科终末病历质量,值得推广应用。Objective To research the influence quality control on comprehensive strengthening nephrology terminals medical record quality. Methods 2547 cases of nephrology terminals medical records in 2013 were selected as the experimental group, and 2373 cases medical records in 2012 as the control group. The experimental group adopt comprehensive strengthening quality control.the control group adopt regular quality control. Comparing number of defects,the average hospitalization medical record score values, and class A rate between two groups. Results The mean medical record evaluation score and records grade rate in experimental group were better than that in control group, while deficit index were contrary, there were statistically significant between two groups. Conclusion Comprehensively strengthening department quality control can effectively improve the nephrology terminals medical records, and should be widely applied.

关 键 词：病案 质控 终末 影响 

分 类 号：R197.323.1[医药卫生—卫生事业管理]