开展精评活动提升病历内涵质量  

Carrying out Fine Evaluation Activities to Improve the Quality of Medical Records

作　　者：刘维 安书杰 张崇霏 肖妹 王宏斌 田妮娜 张珊红 LIU Wei;AN Shujie;ZHANG Chongfei(Xijing Hospital,Air Force Military Medical University,Xi＇an,Shaanxi,710032,China)

机构地区：[1]空军军医大学西京医院,陕西西安710032

出　　处：《中国卫生质量管理》2018年第5期39-40,46,共3页Chinese Health Quality Management

摘　　要：目的持续提升病历内涵质量。方法设定病案首页填写、运行病历质控、终末病案质控、输血病历审核和培训整改5个指标,组织院级评价指导专家小组分批下科室进行病历质量精评专项检查,首次点评后的3个月、6个月、9个月再"回头看"。结果经过初评和"回头看"抽取病历评价并进行前后比较,甲级病案率提升了26.67%,第2轮和第3轮"回头看"甲级病案率较第1轮均有统计学差异(P<0.05)。结论组织院内专家开展"精评病历"活动是提升病历质量的有效方法,操作性强,管理成本低,应继续坚持。Objective To continuously improve the contend quality of medical records. Methods The five indicators were set which included the standard of the front page of the medical record, the medical record process quality control, the final medical record quality control, the blood transfusion medical record review and the training rectification. The hospital-level evaluation and guidance experts team were organized to carry out the special inspection of medical record quality, with recheck after 3 months, 6 months, and 9 months. Results After the initial evaluation and recheck, the medical records were evaluated and compared, the percentage of first-grade medical records increased by 26.67 %, and the percentage of first-grade medical records the second and third rounds of rechecks were statistically different from the results of the first round （ P 〈0.05）. Conclusion Organizing experts in the hospital to carry out the of medical records evaluation activities was an effective way to improve the quality of medical records with strong operability and low management cost, which should continue to be carried out.

关 键 词：病历质量 精评病历 专项检查 

分 类 号：R197.323[医药卫生—卫生事业管理]