某院出院病案检查结果分析及建议  

Analysis and Recommendations on Discharged Medical Record in A Hospital

作　　者：彭晔[1] 张旭刚[1] 郑文选[1] 韩轶超[1] 谢娜[1] 张秀岩[1] 

机构地区：[1]哈励逊国际和平医院,河北衡水053000

出　　处：《中国卫生质量管理》2015年第2期34-36,共3页Chinese Health Quality Management

摘　　要：目的了解病案质量现状,分析影响因素,提出改进建议。方法分内科、外科、妇产科、儿科(小儿内科、新生儿科)4个系统,随机抽取衡水市某三甲综合性医院2013年出院病案各750份,共3 000份,对病案质量进行检查。结果妇产科、儿科甲级病案率均在90%以上,质量较好,内科、外科甲级病案率均低于90%,尤以外科病案质量最差。结论医院应加强电子病历质量监控功能,加强围手术期质量管理,及时反馈质控结果,明确三级医师职责并落实奖惩。Objective To understand the status of medical record, analyze influence factors, and propose recommendations for improvement. Method A random sample of 750 medical records form each of the four departments of internal medicine, surgery, obstetrics and gynecology, and pediatrics, with a total of 3000 medical records, were included for analysis on quality of the medical records in a Three - A general hospitals in Hengshui City in 2013. Result The grade - A medical records rate was above 90% in both Department of Obstetrics and Gynecology, and Department of Pediatrics. However, the grade - A medical records rates in Department of Internal Medicine and Department of Surgery were lower than 90%, especially in the Department of Surgery. Conclusion Hospital should strengthen quality monitoring on electronic medical records, improve perioperative quality management, timely feedback the quality control results, clarify responsibilities of three - level physicians, and implement the rewards and punishment measures.

关 键 词：内外妇儿 病案质量 现状分析 改进措施 

分 类 号：R574.62[医药卫生—消化系统]