不同质控方法在病案质量控制中的应用效果  

Application effect of different quality control methods for the quality of medical records

作　　者：彭盼[1] 杨晓文[2] 

机构地区：[1]山西省人民医院信息管理处,太原030012 [2]山西省人民医院感染管理科,太原030012

出　　处：《中国当代医药》2015年第4期158-159,162,共3页China Modern Medicine

摘　　要：目的比较不同病案质量控制方法对病案质量的影响,为病案书写质控方法的选择提供科学依据。方法采用随机抽样的方法,抽取某院2013年~2014年的病历300份,分别纳入环节质控组、终末质控组、联合质控组,比较各种病案质量控制方法的效果。结果联合质控组的甲级病案率为99%,环节质控组为93%、终末质控组为90%,联合质控组的甲级病案率高于其余两组（P〈0.05）。结论联合质量控制可以更好地保障病案的质量。Objective To compare the influence of different record quality control methods on the quality of the medical record to provide a scientific basis for the selection of the methods of quality control for medical record. Methods Random sampling method is adopted.300 medical records were extracted in our hospital from 2013 to 2014,and they were brought into the link quality control group,the final quality control group,the joint quality control group,the effect of various medical record quality control methods was compared. Results The rate of grade-A case in the joint quality control group was 99%,it was 93% in the link quality control group and 90% in the final quality control group,the rate of the joint quality control group was higher than that the other two groups（P〈0.05）. Conclusion Joint quality control can better ensure the quality of medical record.

关 键 词：电子病历 环节质量控制 终末质量控制 联合质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]