构建病案质量控制体系对终末病案质量的影响  

The Influence of Establishing Medical Record Quality Control System on the Quality of Terminal Medical Records

作　　者：王志莲[1] 崔延华[1] Wang Zhilian Cui Yanhua(Binzhou Medical University Affiliated Hospital, Binzhou 256603, Chin)

机构地区：[1]滨州医学院附属医院,滨州市256603

出　　处：《中国病案》2016年第11期20-22,共3页Chinese Medical Record

摘　　要：目的探讨构建病案质量控制体系,形成科学、系统的病案质量管理模式,全面提高病案质量,规范医疗行为,确保医疗安全。方法 2014年运用前馈控制的理论和方法,以国家卫生行政部门颁发的法律规章为指导,制定了医院病案质量评价标准,建立了三级质控组织,确定质量控制指标,并对全面实施质量控制体系前后的2013年1月-2013年3月、2014年1月-2014年3月各随机抽取的3000份住院病案的书写缺陷率、甲级病案率、出院病案3天回收率进行分析比较。结果通过病案质量控制体系的构建与实施,病案书写缺陷率由全面质量控制前的23.23%降至14.07%;甲级病案率由全面质量控制前的92.03%提高至95.87%;出院病案3天回收率由全面质量控制前的83.87%提高至95.07%。病案缺陷率、甲级病案率和病案3天回收率的差异均有统计学意义(P<0.01)。结论全面、系统的三级质量控制体系的构建与实施,能充分发挥各级病案质量管理组织的监管作用,增强医务人员规范书写病案的能力和自觉性,显著提高病案质量。Objectives To explore how to establish a medical records quality control system, form a scientific and systemic medical record mode, so as to improve the overall medical record quality, regulate medical practice and ensure medical safety. Methods Using the feedforward control theory and method, issued by the administrative department of health of the state laws and regulations as a guide, we formulated the hospital medical record quality evaluation standard, set up three level quality control organization, constitute the quality control indexes, and the implementation of a comprehensive quality control system and defect rate of medical record writing, grade medical record rate, discharge medical record 3 days callback rate were analyzed and compared. Results Through the establishment and implementation of the clinical history quality control system, the clinical history writing defects has declined from 23.23% before the overall control to 14.07%（P〈0.01）; the class A clinical history rate has improved from 92.03% before the overall control to 95.87%; the recovery rate of the clinical history after leaving hospital for three days has improved from 83.87% before the overall control to 95.07%. The last two objects both have been improved（P〈0.01）. Conclusions The construction and implementation of an overall and scientific 3-grade quality control could give full play to the supervision function of medical record quality management organizations at different levels,enhance the ability and self-discipline on writing and improve the quality of medical record.

关 键 词：前馈控制 病案质量 控制体系 

分 类 号：R197.323[医药卫生—卫生事业管理]