住院医师参与病案检查对病案质量的影响  

Impact of Residents to Participate in the Medical Record Check on the Quality of Medical Records

作　　者：邹庞[1] 罗建章[1] Zou Pang Luo Jianzhang(The First Hospital of Longyan, Longyan 364000, Fujian Province, Chin)

机构地区：[1]龙岩市第一医院,福建省龙岩市364000

出　　处：《中国病案》2016年第10期21-22,42,共3页Chinese Medical Record

摘　　要：目的探讨住院医师参与病案检查对其书写的病案质量的影响。方法按是否参与病案检查将研究对象分为实验组和对照组。比较实验组参与病案检查前后的病案优秀率,分别比较实验组和对照组2014年度和2015年度的病案优秀率,利用EXCEL整理数据,并应用统计软件SPSS19.0对病案优秀率进行卡方检验。结果实验组2015年度的病案优秀率明显高于2014年度(P<0.001);2015年度,实验组的病案优秀率明显高于对照组(P<0.001)。结论住院医师参与病案检查可显著改进其书写的病案质量。Objective To investigate the impact of residents to participate in the medical record check on the quality of medical records that written by them.Methods The research objects were divided into the experimental group and control group according to whether or not to participate in medical record check.Compared the excellent rate of medical records before and after participating in medical record check.Compared the excellent rate of medical records that written by the experimental group and control group in 2014 and in 2015.Analyzing the excellent rate of medical records by Excel and Spss19.0.Results The excellent rate of medical records that written by experimental group in 2015 is obviously better than in 2014（P〈0.001）.The excellent rate of medical records in 2015 that written by experimental group is obviously better than control group（P〈0.001）.Conclusion Residents to participate in the medical record check can significantly improve the quality of medical records that written by them.

关 键 词：住院医师 改进 病案质量 

分 类 号：R197.323[医药卫生—卫生事业管理]