环节病历的随机信息化检查与整体反馈  

Randomly Informatization Examination and Overall Feedback of Medical Records Links

作　　者：熊飞[1] 徐寅实[1] 李成义[1] 宋佳[1] 刘冠杉[1] 王笑宇[1] 席林青[1] 尹键[1] 

机构地区：[1]航天中心医院,北京市100049

出　　处：《中国病案》2017年第5期14-16,共3页Chinese Medical Record

摘　　要：目的探索环节病历质量的检查与反馈方法,切实加强临床科室的质控作用,从而提高病历质量。方法分别选取某院2016年3月-2016年3月和2016年7月-2016年10月的出院病案24 230例作为对照组和实验组。回顾性分析随机信息化检查及整体反馈前后两组的环节病历及终末病案质量。使用SPSS19.0统计软件,采用四格表24 230例检验进行分析。结果采取随机信息化检查及整体反馈后,环节病历不及时率降至18.34%(χ~2=20.909,P<0.05)、终末病案内涵质量缺陷降至13.91%(χ~2=304.111,P<0.05)。结论转换管理思路,环节病历的随机信息化检查及整体反馈是提高病历质量的有效方法。Objectives To explore methods of examination and feedback of medical records links, so as to improve the quality control function of clinical departments definitely. Methods 24230 cases of discharged medical records during period of March to June and July to October in 2016 of a hospital were selected as control group and experimental group. To conduct retrospective analysis on the terminal medical records quality before and after the randomly informatization examination and overall feedback. To make analysis on 24230 eases with fourfold table by SPSS19.0 software system. Results After the application of the new examination and feedback method, not timely rate of the quality of medical records was reduced to 18.34% （χ^2=20. 909, P〈0. 05） and the rate of diagnosis and treatment defect was reduced to 13.91% （χ^2=304. 111,P=0. 000, P〈0. 05）. Conclusions It is an effective method to improve the quality of medical records by changing management thoughts, making randomly informatization examination and overall feedback of medical records links.

关 键 词：环节病历 信息化 反馈 

分 类 号：R197.323[医药卫生—卫生事业管理]