病案翻拍过程中发现的问题与对策  

Solutions to the Problems of Digital Copying of the Medical Records

作　　者：陶润英[1] 王殷姝 余达春 刘敏荣[1] 谢文洁[1] 

机构地区：[1]解放军第九四医院信息科,南昌市330002 [2]上海中医药大学附属龙华医院,上海市200030

出　　处：《中国病案》2017年第2期39-41,共3页Chinese Medical Record

摘　　要：目的通过加强病案翻拍的各项质量管理,提高数字化病案质量。方法利用某院在病案翻拍过程中陆续发现的问题进行统计分析,针对问题采取以病案管理人员为主导的全程质量控制模式,完善三级质检机制,加强病案原始材料质控,规范数字化翻拍流程,对翻拍人员进行有关知识培训等措施。比较干预前后翻拍病案的质量变化。结果干预前病案翻拍质量合格率为94.88%,干预后提高到99.31%,经卡方检验,差异有统计学意义(P<0.005)。结论加强病案翻拍的全程质量管理,有效提高了翻拍病案质量,降低了病案的返拍率,保证了纸质病案的安全和完整的储存,充分发挥了翻拍病案的使用价值。Objectives To improve the quality of digital medical records by means of strengthening quality control in copying. Methods To conduct analysis on the problems of the paper medical records digitalization in our hospital and take such measures as establishing and improving the system of three-level quality control, strengthening the quality control of the original paper medical records, normalizing the process of digital copying and conducting staff training for medical records, and compare the quality difference of the medical records before and after the countermeasures. Results Since the effective measures were taken, the qualified ratio of the copying records has been increased from 94. 88% to 99. 31%, and the difference was statistically significant （P〈0. 005）. Conclusions The quality of medical records in digitalization has greatly improved under the full quality control measures, and the number of the recopying records has been reduced. As a result, we can make good use of the digital copying medical records.

关 键 词：病案翻拍 质量管控 改进措施 

分 类 号：R197.323[医药卫生—卫生事业管理]