病历质量现状分析与对策  

Current Situation Analysis on the Quality of Medical Records in a Hospital and Relevant Countermeasure

作　　者：李准[1] 宋萍[1] 赵文龙[2] 

机构地区：[1]重庆医科大学附属儿童医院病案统计科,重庆市400014 [2]重庆医科大学医学信息学院,重庆市400016

出　　处：《中国病案》2016年第1期14-17,共4页Chinese Medical Record

摘　　要：目的了解病历书写质量现状,发现其中存在的问题,提出对策,为今后科学制定病历质量控制方案提供借鉴。方法收集2012年至2014年病案首页、中间环节、终末病案的质量控制结果,运用SPSS17.0软件进行统计分析。结果 2014年病案首页质控中排名前三的问题是手术及操作书写不规范、临床路径管理未填或填写有误、损伤与中毒的外部原因漏填,分别占22.73%、19.93%、14.16%;中间环节质控中排名前三的问题是医嘱缺签名、修正诊断遗漏、医患沟通未按规定次数记录,分别占22.46%、17.31%、12.95%;病案终末质控中排名前三的问题是体格检查缺陷、现病史记录缺陷、个人史或过去史或家庭史记录缺陷,分别占7.67%、5.08%、5.08%。结论病历书写网络系统功能不完善、医师自身责任心不强、临床科室自查不严以及管理部门培训不到位是导致病历缺陷的主要原因。因此,建立病案首页数据质量控制功能模块、医师自身改变观念、临床科室加大自查力度、管理部门加大培训力度对提高病历质量具有重要意义。Objective To understand current situation of the quality of medical records, discover the problems existed,put forward countermeasures and provide reference for scientific making of quality control scheme of medical records. Methods To collect the quality control results of the medical records which included home pages, intermediate links and terminal medical records from 2012 to 2014, then conduct statistical analysis with the SPSS17.0 software. Results The top three problem of quality control of home pages included writing operation names and operation names were not standard, lack of filling in situation of clinical pathway management or filling errors, lack of filling in external causes of injury and poisoning, which accounted for 22.73%, 19.93% and 22.73% respectively. The top three problem of quality control of intermediate links included doctor＇s advice without signature, not correct diagnosis, not enough record number of doctor-patient communication, which accounted for 22.46%, 17.31% and 12.95% respectively. The top three problem of terminal quality control included lacking of physical examination record, history of present illness record, personal history or past history or family history record, which accounted respectively for 7.67%, 5.08% and 5.08% in 2014. Conclusions The reasons caused the defects in the medical records included the function of medical records writing network system is not perfect, the doctor＇s own responsibility was not strong, self inspection of was not strict and management training was not in place. So it was of great importance to establish a function module of data quality controlling of medical record home pages, doctors should change their mind themselves, clinical departments should strengthen self inspection and the management department should increase their intensity of training for improving the quality of medical records.

关 键 词：病历质量 首页质控 环节质控 终末质控 

分 类 号：R197.323[医药卫生—卫生事业管理]