某院终末病案质量现状分析  

Analysis on the Quality of Final Medical Records in a Hospital

作　　者：李凌[1] 唐瑶 邓杰芳[1] 尹龙燕[1] Li Ling;Tang Yao;Deng Jiefang;Yin Longyan(Guangzhou First People's Hospital, Guangzhou 510180, Guangdong Province, China)

机构地区：[1]广州市第一人民医院,广东省广州市510180

出　　处：《中国病案》2019年第4期16-19,共4页Chinese Medical Record

摘　　要：目的探讨某院病案质控流程改革前后终末病案质量的变化,为科学化的病案管理提供依据。方法采用回顾性研究的方法,按照某院《病历书写手册》和原卫生部《病案书写基本规范》等要求,对2015年和2018年同期出院的终末病案质量进行质量评价,比较分析病历书写质量。统计方法有描述性统计分析和Fisher确切概率卡方检验。结果 2018年1季度主要缺陷前面三位的是缺会诊单36人次、缺与诊断相关的检查报告单30人次、缺输血知情同意书28人次。而非主要缺陷是病案首页遗漏门诊诊断23人次,病案首页漏填或者填写错误20人次和缺医师签名19人次。结论加强病历书写各个环节的管理,注意病历完整性的检查,同时加强书写质量相关内容培训与考核,提高临床医师责任心和法律意识,对于提高病历书写内涵质量具有切实意义。Objective To provide scientific basis for medical record management, the quality change of final medical record before and after the reform of medical record quality control process in a hospital was discussed. Methods A retrospective study was conducted to evaluate the quality of final medical records in 2015 and 2018 in accordance with the requirements of the Handbook of Medical record Writing in a certain hospital and the Basic Standard of Medical Record Writing in the former Ministry of Health, and a comparative analysis of the quality of medical record writing was carried out during the same period in 2015 and 2018. The statistical methods include descriptive statistical analysis and Fisher exact probability Chi-square test. Results The first three major defects in the first quarter of 2018 were lack of consultation list 36 person-times, lack of diagnosis-related examination report sheet 30 person-times,and lack of blood transfusion informed consent 28 person-time. Non-major defects were the omission of 23 out-patient diagnoses on the home page, the omission or error in filling in the front page, and the lack of signature of 19 doctors on the first page. Conclusion It is of practical significance to strengthen the management of every link of medical record writing, to pay attention to the examination of the integrity of medical records, and to strengthen the training and examination of relevant contents of writing quality, and to improve the sense of responsibility and legal consciousness of clinicians.

关 键 词：终末病案 病案质量 缺陷 

分 类 号：R197.323[医药卫生—卫生事业管理]