病案科内部工作质量监控方法的实践研究  

Research on the Practice of Quality Monitoring Methods of Internal Work of Medical Records Department

作　　者：周婧雅[1] 赵青[1] 赵轶超[1] 赵晓娟[1] 刘海[1] 刘爱民[1] 

机构地区：[1]北京协和医院,北京市100730

出　　处：《中国病案》2017年第4期1-4,共4页Chinese Medical Record

摘　　要：目的探讨病案科内部工作质量监控方法的可行性。方法梳理可用于病案科内部工作环节质量监控的指标,分析实际工作中主要环节系统监控数据及人工质控结果。结果病案重建率、门诊病案及时发送率、门诊病案逾期未归率及出院病案48小时内回收率等指标监测结果可以用于发现目前工作中存在问题及漏洞。专人质控方式能够明显改善整理组工作质量,使总体整理缺陷率从13.2%降低至9.1%,P<0.05,其中主要整理缺陷占比例由6.5%降低至3.3%,P<0.05。而专人编码质控对编码质量改善效果不明显,P>0.05。结论以医院局域网下的科室监控系统(示踪系统)为手段、主要环节专人监控为重点的病案科内部工作质量监控模式能够及时反馈工作不足,并能够监测管理效果,有助于病案内部工作质量提升。Objectives To investigate the feasibility of quality monitoring methods of internal work in medical record department. Methods Based on the quality monitoring indicators for the main parts of internal work in medical record department, we analyzed monitor data either from local net information system or manual auditing results in practical work. Results The reestablishment rate of medical record number, timely delivery rate of outpatient medical records, overdue and unreturnable rate of outpatient medical records as well as the collecting rate of inpatient medical records in less than 48 hours can be used to find the problems and loopholes in the current work.Auditing can significantly improve the quality of documentation filing, and the overall defect rate of filing reduced from 13.2% to 9.1%, P〈0.05, in which the rate of major defects reduced from 6.5% to 3.3%, P〈0.05.However, the effect of quality control on coding quality enhancement was not obvious, P〉0.05. Conclusion It is practically confirmed that the means of quality monitoring by combination of medical record tracing system and the manual check for filing and coding, can timely and objectively reflect the deficiency and limitations of current work and help to improve the quality of internal work of medical record management.

关 键 词：病案 内部工作 质量监控 

分 类 号：R197.323[医药卫生—卫生事业管理]