病案首页质量控制体系的建立与应用效果评价  

Establishment and Effectiveness Evaluation of a Quality Control System of the Home Pages in Medical Records

作　　者：杨婷[1] 童强[1] 涂自良[1] 方孝梅[1] 袁瑞良[1] 

机构地区：[1]湖北医药学院附属十堰市太和医院,十堰市442000

出　　处：《中国病案》2015年第1期26-28,共3页Chinese Medical Record

摘　　要：目的探讨和完善病案首页质量控制体系,提高病案首页信息内涵质量。方法制定一套按信息类型分类、百分制细化的病案首页质量评分标准,采取普查和抽样检查相结合的方式,每月进行病案首页质量评比,质量检查与质控考核分离,由出院科室负责病案首页质量。结果医院管理层和临床科室高度重视,病案首页质量整体提升,全院各科得分均在90分以上,最高平均得分为99.9分。结论病案首页质量控制体系依托系统过程控制、加强病案首页质量培训、实行四级监控制度和集合所涉及医务人员的努力,实施效果显著,具有很好的示范作用。Objectives To investigate and consummate a quality control system of the home pages in medical records,and improve the connotation quality of the information in home pages.Methods To formulate a series of quality evaluation criteria of home pages classified by information type and refinement of centesimal system,then conduct quality comparison of home pages monthly with the mode of general survey and sampling check,separate quality examination from quality control assessment,and the discharged department was responsible for the quality of home pages.Results This system attached great attention of the hospital managers and clinical departments,and the quality of home pages was overall increased.The average score was above 90 of all departments of the hospital,and the highest average score was 99.9.Conclusions With the help of process control system,training to improve the quality of first page,practice of the four class monitor system as well as the efforts of the staff were involved,the implementation results of the home pages quality control system was effective,and had a good demonstration effect.

关 键 词：病案首页 质量控制 效果 

分 类 号：R197.323[医药卫生—卫生事业管理]