归档病历管理在医疗质量管理中的应用研究  

Applied research of archived medical record management in medical quality management

作　　者：李丽 肖彭 张倩 刘英明 刘晓平[2] Li Li;Xiao Peng;Zhang Qian;Liu Yingming;Liu Xiaoping(Quality Control Department,Affiliated Hospital of Jiujiang University,Jiujiang 332000,Chin)

机构地区：[1]九江学院附属医院质控科,332000 [2]赣南医学院第一附属医院

出　　处：《中华医院管理杂志》2018年第8期702-704,共3页Chinese Journal of Hospital Administration

摘　　要：目的总结我院实施归档病历价值基金对医疗质量管理状况的影响并提出改进策略。方法回顾性分析2015年和2016年的1149份病历评分单，并对197份评分单中的内涵扣分比进行比较，统计分析归档病案的甲级病案率、乙级病历的缺陷构成、病历内涵扣分比、质控专家的能力（纠错比）。结果归档病历价值基金实施后，病历质量明显提高，甲级病历率逐步提高，从89％提高到95％；单项否决项乙级病历比率明显减少，差异有统计学意义（P〈0．05）；病历内涵扣分占比增加（t=-4．409，P〈0．05）；质控能力较强（纠错比≥80％）的专家人员比例得到提高（从32．2％到50．9％），差异有统计学意义（P〈0．05）。结论归档病历管理后，病历质量尤其是病历内涵质量不断提高，部分质控专家的能力得到培养，院科两级质控管理体系得到发展。Objective To summarize the impacts of the archived medical record value fund as established by the hospital, on the medical quality management, and propose improvement strategies. Methods Retrospective analysis was made on 1 149 medical record scoring sheets, and the rate of connotations deducting scores in 197 of such sheets were compared. A statistical analysis was made on the archived medical records, regarding the rate of grade A medical records, defects composition of grade B medical records, the rate of connotation deducting scores, and the ability of the quality control experts （ error correction ratio）. Results The archived medical record value fund has pushed up significantly the quality of medical records. For example, the rate of grade A medical records rose step by step from 89% to 95% ; the rate of grade B medical records with single-item vetoes fell sharply, a difference of statistical significance （ P 〈 0.05 ） ; the connotation quality management of medical records was constantly improving, with the rate of connotation deducting scores gradually elevating （ t = - 4. 409, P 〈 0.05 ） ; the proportion of experts with strong error correction ability （ error correction ratio ≥80% ） was elevated from 32. 2% to 50. 9% , a difference of statistical significance （ P 〈 0.05 ）. Conclusions Arehived medical record management can encourage medical quality management. The quality of medical records, especially the connotation quality of medical records has been improved. The ability of some quality control experts was also enhanced. The quality management system at hospital and department levels has made major progress.

关 键 词：归档病历价值基金 病历内涵质量 内涵扣分 纠错比 质控管理体系 

分 类 号：R197.323[医药卫生—卫生事业管理]