某医院运行病历缺陷分析与改进措施  

Quality analysis and improvement measure on running medical records in a hospital

作　　者：施琼[1] 张红英[1] 吕裕霞[1] 张健[2] 

机构地区：[1]中国人民武装警察部队总医院质量管理科,北京市海淀区永定路69号100039 [2]中国人民武装警察部队总医院眼科,北京市海淀区永定路69号100039

出　　处：《中国医院》2014年第9期58-59,共2页Chinese Hospitals

摘　　要：目的:通过实时监控、及时反馈,提高运行病历书写质量。方法:应用军卫一号病案质量监控系统随机抽查某医院运行病历3613份,进行网上实时监控,对这些病历的缺陷进行统计分析。结果:在检查中缺陷病历率占5.67%,通过实时监控,运行病历缺陷率不断降低,2013年8月-10月分别为8.4%、4.9%和3.7%。结论:实时监控是提高运行病历质控效率、提高病历质量的有效方法。To improve the quality of running medical record through real-time monitoring and feedback on time. Methods： 3613 running medical records are selected randomly through using the medical record quality monitoring system had statistical analysis on the problem during monitoring. Results： In 3613 medical records, the defect rate accounts for 5.67% of all defects. Through real time monitoring, the defect rates of medical record were reduced month by month from August to October, which defect rates were respectively 8.4%,4.9%,3.7%. Conclusion： Real time quality monitor is a high efficiency method to improve work efficiency of quality control of medical records and improve medical records quality.

关 键 词：运行病历 实时监控 缺陷分析 

分 类 号：R197.323[医药卫生—卫生事业管理]