北京地区病案质控人员水平测试结果分析  

Proficiency Test Results of Medical Record Quality Control Personnel in Beijing Region

作　　者：白雪娟[1] 李斌[1] 胡燕生[1] Bai Xuejuan Li Bin Hu Yansheng(Beijing Medical Records Quality Control and Development Center. Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing 100020, China)

机构地区：[1]首都医科大学附属北京朝阳医院北京市病案质量控制和改进中心,北京市100020

出　　处：《中国病案》2016年第11期12-14,共3页Chinese Medical Record

摘　　要：目的了解目前病案质控人员的实际质控水平,为今后病案质控人员的培训工作提供依据。方法由出题专家按照原卫生部《病案书写基本规范》编写存在常见书写缺陷的临床病案,作为测试的考题,同时出具标准答案。参加测试的病案质控人员在规定的时间内进行闭卷答题。试卷由经过培训的病案质控专家统一批阅,100分为满分,60分为及格。按照医院类别、医师类别、试题类别的得分情况进行汇总。结果参考人数240人,平均分59.60分,及格率55.42%。测试成绩二级甲等以上医院的质控人员水平相对较高,三级甲等医院的及格率为68.79%,三级医院及格率为73.53%,二级甲等医院及格率为62.07%,二级及其它医院的成绩相对较低,及格率为35.56%。首页部分得分率最高,为76.73%,出院小结部分得分率最低,为37.71%。临床医师的考试成绩高于非临床医师的考试成绩,前者的及格率为80.74%,后者的及格率为22.86%。结论病案质控人员的质控水平需要进一步的提高,尤其是二级以下医院的病案质控人员的质控水平需要大幅提高;临床医师的病案质控水平较高,病案终末质控应首选临床医师来承担。病案质控人员在质控中的薄弱环节是术前小结、术前讨论、手术记录、出院小结,有待进一步的加强。Objective To understand the actual quality control level of medical record quality control personnel at present, and provide evidence for the training work on them. Methods According to the ＂Medical Record Writing Basic Specifications＂ announced by the health ministry, the experts chose the common writing errors as the test questions, and also issued a standard answer. The quality control personnel requested for the answer within the stipulated time. The examination papers were marked by the experts who received training, the full score was 100 and the pass score was 60. To make a summary according to the score of hospitals sorts, doctors and the examination papers. Results There were 240 cases in the examination, the average score was 59.60, the pass rate was 55.42%.The scores of the quality control personnel in above Class A second grade hospital were relatively high, the pass rate of Class A and Tertiary Hospital was 68.79%, in Tertiary Hospital was 73.53%, and in Class A second grade hospital was 62.07%. The scores of the quality control personnel in other second grade hospital were relatively low,the pass rate was 35.56%, the score rate of front pages was the highest, which was 76.73% and the discharge summary was the lowest, which was 37.71%. The scores of clinical doctors were higher than other doctors, the pass rate of the former was 80.74% while the latter was 22.86%. Conclusions The level of the quality control personnel still need further development, especially that in second grade hospitals. The quality control level of clinical doctors was relatively high, and the terminal control of medical records should be given to them. The weak links of the medical records quality control staff included preoperative summary, preoperative discussion, operation records and discharge summary.

关 键 词：北京地区 病案质控 终末病案 水平测试 

分 类 号：R197.323[医药卫生—卫生事业管理]