追踪方法学在病案管理工作质量持续改进中的应用  

Application of Tracking Methodology in the Continuous Quality Improvement of Medical Record Management

作　　者：谭艺灵[1] 彭三玲 杨梅芳[1] 李锦秀[1] 胡月梅[1] 刘捷[1] 

机构地区：[1]广东省东莞市人民医院病案室,东莞市523059

出　　处：《中国病案》2016年第8期14-16,共3页Chinese Medical Record

摘　　要：目的研究追踪方法学在病案管理工作持续质量改进中的应用效果。方法于2015年1月组建病案追踪方法学工作小组,对病案管理工作流程各个环节进行追踪管理,从系统上查找流程中的缺陷和不足,经过评估和分析,提出整改措施,加以改进和优化,达到完善工作制度、优化流程、提高工作质量的效果。结果出院病案72小时回收率由应用追踪方法学前的83.62%提高到92.18%;病案复印满意度由应用前的93.55%提高到98.19%;ICD编码准确率由应用前的91.06%提高到98.12%;病案首页缺陷率由应用前的26.64%降低至9.57%。结论通过应用追踪方法学,能够有效改进病案管理工作,从而促进病案管理工作质量持续提高。Objectives To study the application effect of the research tracking methodology in the continuous quality improvement of medical record management. Methods To establish medical records tracking methodology group work in January 2015, conduct tracking management on the links in medical record management process, search defects and deficiencies in the process from the system. To put forward rectification measures and make improvement and optimizing through the assessment and analysis, thus to realize the effect of complete system, optimize processes and improve the quality of the work. Results The discharge records of 72 hours recovery rate increased from 83.62% to 92.18% by the application of tracking methodology. The satisfaction rate of medical records duplication increased from 93.55% to 98.19%, and the accuracy rate of ICD coding increased from 91.06% to 98.12%, the defects rate of front pages in medical records decreased from 26.64% to 9.57%. Conclusions The medical record management could be improved effectively by using the tracking methodology, and the quality of the medical record management could be improved continuously.

关 键 词：追踪方法学 病案管理 应用 

分 类 号：R197.323[医药卫生—卫生事业管理]