乌鲁木齐市某三甲医院健康体检主检报告现况分析  

A case study of the chief inspection conclusions from physical examination reports of a Tertiary Ⅲ-A hospital in Urumqi

作　　者：吴建荣[1] 张明琛[1] 杨晓萍[1] 王淑霞[1] Wu Jianrong;Zhang Mingchen;Yang Xiaoping;Wang Shuxia(Health Management Center, the First Teaching Hospital of Xinjiang Medical University, Urumqi 830054, Chin)

机构地区：[1]新疆医科大学第一附属医院健康管理中心,乌鲁木齐830054

出　　处：《中华健康管理学杂志》2018年第3期208-211,共4页Chinese Journal of Health Management

基　　金：新疆维吾尔自治区科技计划软科学项目（2016D07014）;中华医学会医学教育分会中国高等教育学会医学教育专业委员会医学教育研究课题（2016B-QK022）

摘　　要：目的分析新疆医科大学第一附属医院健康管理中心主检报告现况，为提高主检报告质量提供参考依据。方法纳入7位主检医师2017年9至10月的12489份主检报告，由3名高年资医师作为质控医师从主检报告标准化疾病诊断分类书写、结论及阳性结果排序、一元化诊断分析的一致性3个方面盲法对主检报告进行质控分析。结果7位主检医师主检报告标准化疾病诊断分类书写一致性在95.2%-96.5%之间、体检结论及阳性结果排序的一致性在94.0%-96.1%之间，各医师间差异无统计学意义（χ2=9.906、9.740，P〉0.05）；但7位主检医师主检报告的一元化诊断的一致性在86.2%-94.6%之间，各医师间差异有统计学意义（χ2=92.990，P〈0.001）。结论不同主检医师主检报告可在标准化疾病系统分类书写、体检结论及阳性结果排序等方面做到规范统一，但一元化诊断存在差异，仍需加强培训。ObjectiveThis paper analyzed the conclusion report of physical examinations by the chief inspection physician from the Health Management Center, The First Teaching Hospital of Xinjiang Medical University in Urumqi, to examine the quality of these reports. The research aimed to provide a reference for improving the quality of the chief physician＇s conclusions from physical examinations.MethodUsing the method of blinding, three senior physicians as quality control doctors analyzed the value of concordance of 12 489 conclusions from physical examinations by seven chief inspection physicians made from September to October 2017 based on three aspects, including standardization of classified disease-diagnosis handwriting, conclusions of physical examination and sequence of positive results, and unified diagnosis.ResultsThe results showed that value of concordance of standardization of classified disease-diagnosis handwriting of the reports by the seven chief inspection physicians was 95.2%-96.5% and of conclusions of physical examination and sequence of positive results was 94.0%-96.1%. Additionally, these two values indicated no statistically significant differences among the seven chief inspection physician （χ2=9.906, 9.740 respectively, P〉0.05）. However, the concordance value of unified diagnosis by the seven chief inspection physicians was 86.2%-94.6%, displaying statistically significant differences among the chief inspection physicians （χ2=92.990, P〈0.001）.ConclusionIt was concluded through the research that differences in the chief inspection physicians＇ reports of physical examination reached normalization and unification in aspects of standardization of classified disease-diagnosis handwriting, and conclusions of physical examination and sequence of positive results. However, statistical variations in aspects of unified diagnosis revealed that training should be conducted for the chief inspection physician for physical examination.

关 键 词：质量控制 体格检查 主检报告 

分 类 号：R194.3[医药卫生—卫生事业管理]