以问题为导向的病案质量监控  

Problem Oriented Medical Record Quality Monitoring

作　　者：陈冬连[1] 苏静[1] 洪雅君[1] 龚黛琛[1] 朱艳艳[1] Chen Donglian;Su Jing;Hong Yajun;Gong Daichen;Zhu Yanyan(The 174 hospital of PLA, Xiamen 361003, Fujian Province, China)

机构地区：[1]中国人民解放军第174医院,厦门市361003

出　　处：《中国病案》2017年第12期30-32,共3页Chinese Medical Record

摘　　要：目的研究分析以问题为导向的病案质控管理模式对于终末病案质量的影响效果。方法通过以问题为导向,重点的监控临床科室(外科病区)病历书写的缺陷情况,同时研究不同病区的病历书写缺陷项目的分布和原因。结果问题管理模式后,观察组(外科病区)病案合格率89.2%,内科组90.7%,外科组与内科组合格率相差1.5%。2016年和2017年1月-3月同期抽查合格率对比,2016年合格率79.9%提升至2017年的90.9%,结论根据采取问题管理质控模式发现的病历书写缺陷类型和原因,采取对应的改进措施,可以减少出院病案缺陷,显著提高出院病案的合格率。Objective The effect of the problem oriented medical record quality control model on the quality of final medical records was analyzed. Methods By problem oriented, key monitoring clinical departments（Department of surgery） medical record defects. At the same time, the distribution and reasons of medical record defect items in different wards were studied. Results Problem management model, the passing rate of medical record in observation group（Department of surgery） was 89.2%, The combination rate was 90.7%. The difference between the surgical group and the internal medicine unit was only 1.5%. The observation group was better than the control group. Conclusion According to the problems of management take quality control mode that medical records defect types and reasons, to take corresponding improvement measures, can reduce the defects of medical records,improve the qualified rate of medical records.

关 键 词：病案质控 问题管理 病历书写 

分 类 号：R197.323[医药卫生—卫生事业管理]