1560份住院病案终末质控分析  

Final Quality Control of 1560 Cases of Hospitalization Medical Records

作　　者：李雪梅 陈阿芬[1] 洪玲玲[1] 卢介珍[1] 

机构地区：[1]厦门大学附属第一医院病案室,福建厦门361003

出　　处：《中国卫生标准管理》2016年第20期14-16,共3页China Health Standard Management

摘　　要：目的探讨病案终末质控在病案质控中的重要作用。方法以JCI病历评审表为标准,对1 560份某科室病案进行检查,分析缺陷。结果住院病案书写质量缺陷前5位分别是首页缺陷462例(29.62%)、连续性用药协调表缺陷401例(25.71%)、医师评分表缺陷300例(19.23%)、病程记录缺陷296例(18.97%)和手术单缺陷186例(11.92%)。结论病案终末质控有助于查找病案缺陷的根本原因,对于病案质量的改进有重要意义。Objective To discuss the effects of final quality control on quality control of medical records. Methods 1 560 copies of medical records were checked and analyzed with JCI medical record review form. Results The former 5 defects of medical records were home page defects 462 cases（29.62%）,continuity coordinate table defects 401 cases（25.71%）,rater check list defects 300 cases（19.23%）,course record defects 296 cases（18.97%）and operation record defects 186 cases（11.92%）,respectively. Conclusion Final quality control of medical records helps to find the primary causes of the medical record defects and has important significance for the quality improvement of medical record.

关 键 词：病案 终末质控 缺陷 

分 类 号：R197.323[医药卫生—卫生事业管理]