环节中的病案质量监控与干预  

The Quality Monitoring and Intervene of Link Medical Records

作　　者：王莹[1] 刘克新[1] 

机构地区：[1]中国人民解放军总医院病案管理科,北京市100853

出　　处：《中国病案》2015年第4期21-23,共3页Chinese Medical Record

摘　　要：目的通过对出院病案回收中质量检查,对存在的问题缺陷进行归纳分析,为规范出院病案质量管理提供参考。方法对某医院2014年7月-9月33673份出院病案存在的缺陷问题进行有效数据统计,分析缺陷原因,制定干预措施。结果 33673份出院病案,主要问题条目3620项,主要分布在外科,缺陷率占85.49%。干预后病案缺陷问题发生率总体呈下降趋势,平均下降了0.06个百分点。结论加强医院病案管理责任制,增强环节中病案质量监控与沟通,强化各级医师的质量意识及风险意识,规范病案书写质量及培训机制,是促进全院病案质量提高的有效措施。Objective To exam the quality of discharged medical records, sum up and analyze the exist problems,to provide references for discharged medical records quality management. Methods Analyze the problems of 33673 discharged medical records during July and September in 2014, find the causes of defects and make measures.Results There were 33673 discharged medical records and 3620 main items during July and September in 2014. The main items mainly distribute in surgery, defect rate is 85.49%. The defect rate descend after intervene, decline 0.06% on average. Conclusion We should strengthen the hospital medical record management responsibility,enhance the monitoring and communication in the link of medical records management, consolidate doctors＇ consciousness of quality and risk, norm the medical records writing quality and training mechanism, promote the improvement of medical records quality.

关 键 词：环节病案 质量监控 干预 

分 类 号：R197.32[医药卫生—卫生事业管理]