综合医院手术科室与非手术科室间临床路径运管质量比较  

Comparison of Clinical Path Transportation Quality between Surgical Departments and Non Surgical Departments in A General Hospital

作　　者：龚伟伟[1] 赵太宏[1] 肖雨龙[1] 业海燕[1] 

机构地区：[1]南京医科大学附属南京医院(南京市第一医院)医务处,南京市210006

出　　处：《中国病案》2017年第4期27-29,共3页Chinese Medical Record

基　　金：江苏现代医院管理研究基金立项课题(JSY-3-2015-042);江苏现代医院管理研究基金立项课题(JSY-2-2016-061);南京医科大学科技发展基金面上项目(2015NJMU063);2016年度南京市卫生计生委科技发展资金立项项目(YKK16121)

摘　　要：目的调查与比较某三甲综合医院手术科室与非手术科室间临床路径运管质量。方法随机抽取自2015年9月至2016年3月的临床路径出院病案180份,分8个质控点进行检查,比较手术科室与非手术科室临床路径运行质量;利用《临床路径管理记录质控检查表》,比较临床路径管理质量。结果手术科室临床路径运行质量监控总体不合格率(233项,占比32.36%)明显高于非手术科室(79项,占比12.54%)(χ~2=28.56,P<0.01),手术科室临床路径管理质量低于非手术科室(t=18.56,P<0.01)。结论由于疾病特点、诊治流程等不同,基于电子病历管理模式下手术科室临床路径管理明显差于非手术科室管理,临床路径管理应"因病而异、因科而异",同时加强信息支持。Objective To survey and compare the quality of clinical path transportation operation quality between surgical departments and non surgical departments in a general hospital. Methods 180 medical records from September 2015 to March 2016 were randomly selected, eight quality control points were examined, compare clinical pathway operation quality between surgical departments and non surgical departments; using ＂clinical pathway management record quality control check list＂, to compare the clinical path management quality. Results The overall failure rate of surgical departments clinical pathway operation quality（233, accounting for 32.36%）was significantly higher than that of non surgical departments（79, accounting for 12.54%）（χ^2=28.56, P〈0.01）,surgical department clinical pathway management quality is lower than that of non surgical departments（t=18.56,P〈0.01）. Conclusion The characteristics of disease, diagnosis and treatment process of different surgical departments clinical pathway management of electronic medical record management mode is significantly worse than the non surgical departments management based on the clinical pathway management. Clinical pathway management should depend on the different diseases and different departments, and strengthen information support.

关 键 词：临床路径 病案质量 质控 

分 类 号：R197.323[医药卫生—卫生事业管理]