全面质量监控对终末病历质量的影响分析  

Impact Analysis of Total Quality Supervision to the Quality of Terminal Medical Records

作　　者：孙丽[1] 陈丽娟[1] 吴进军[1] 梁翠翠[1] 

机构地区：[1]广东医学院附属医院,湛江市524001

出　　处：《中国病案》2015年第3期8-10,共3页Chinese Medical Record

基　　金：广东省湛江市科技攻关计划项目课题(2012C3101037)

摘　　要：目的通过对全面质量监控实施前后病案的比较,了解病历缺陷的分布和原因,分析实施病历全面质量监控对终末病历质量的影响,探讨提高终末病历质量的措施。方法采用随机分层抽样方法,抽取全面质量监控实施前后各1260份病案进行分析,比较两组病案平均住院病案评分、病案缺陷频次、病案缺陷率和甲级病案率。结果在实施全面质量监控后,平均住院病案评分的分值由94.1分提高到96.3分,甲级病案率由全面质量监控前的93.5%上升至98.4%,平均住院病案评分和甲级病案率均有显著提高(P<0.05);平均每份病案缺陷频次由监控前的7.8频次下降至监控后的2.7频次,病案缺陷率则由全面质量监控前的46.8%下降至监控后18.3%,平均病案缺陷频次和病案缺陷率均有显著下降(P<0.05)。结论在医院管理过程中,实施全面质量监控,加强运行病历环节质量检查,完善病案质量的信息反馈体系,可有效提高住院病案评分和医院的甲级病案率,减少病案缺陷,降低病案缺陷率,以达到提高终末病案质量的目的。?Objectives To understand the distribution and reasons of medical records defects through the comparison before and after the implementation of total quality supervison. analyze the impact of total quality supervision to the quality of terminal medical records and investigate measures to improve the quality of terminal medical records. Methods 1260 cases of medical records were selected by randomly cluster sampling methods before and after total quality supervision. then compare the average scores. the average defects frequency and defect rates and class A rates of terminal medical records between the two groups. Results After the implementation of total quality supervision. the average score of medical records was increased from 94.1 to 96.3. the class A rate was increased from 93.5% to 98.4%. which were significantly higher than before（P〈0.05）. The average defect frequency was decreased from 7.8 to 2.7. and defect rates was decreased from 46.8% to 18.3%. which were significantly lower than before（P〈0.05）. Conclusions We should perform the total quality supervision in the management of the hospital. strengthen the inspection of running medical records and improve the feedback system. and we could improve the average score and class A rate of medical records. decrease average defect frequency and defect rates. thus reach the goal of the improvement of terminal medical records quality.

关 键 词：全面质量监控 终末病历 质量 

分 类 号：R197.323[医药卫生—卫生事业管理]