沟通在病案质控管理中的作用  

Effect of communication in the quality control management of medical records

作　　者：陈章晓 张苑 孙欣燕 孙蓉蓉[2] 孙冬梅[2] Chen Zhangxiao;Zhang Yuan;Sun Xinyan;Sun Rongrong;Sun Dongmei(Forein Affairs Office,Nanjing Drum Tower Hospital Affiliated to Nanjing UniversityMedical School,Nanjing 210008,China;Quality Management Office,Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School,Nanjing 210008,China)

机构地区：[1]南京大学医学院附属鼓楼医院外事办公室,江苏南京210008 [2]南京大学医学院附属鼓楼医院质量管理办公室,江苏南京210008

出　　处：《江苏卫生事业管理》2019年第10期1257-1260,共4页Jiangsu Health System Management

基　　金：2015年南京大学医院管理研究所课题(NDYG2015016)

摘　　要：目的:调查江苏某三甲医院在病案质控模式转变后病案质量的变化情况,分析不同沟通方式对病案质量的影响,为病案质控管理工作提供一定的思路。方法:实验组为2018年3—9月多维沟通方式下在职医师参与质控的病案1897份,对照组为2017年3—9月孤立型沟通方式下退休专家质控的病案1189份,对比两组病案的甲级率、乙级率、丙级率情况。结果:与对照组相比,实验组甲级病案率为96.47%,乙级病案率为2.63%,丙级病案率为0.896%,实验组甲级率明显高于对照组,乙级率和丙级率低于对照组,抽取病案数量占出院病案比率提高了0.89%,差异均具有统计学意义。结论:四级质控体系完善后,在职医师参与病案质控管理,可以建立线上和线下双向反馈机制,形成多维沟通方式,有利于充分调动临床医生参与病历质量管理的积极性,推动病案质控管理工作,提高病历质量。Objective:To analyze the effect of application of multi- dimension communication on quality of medical records in a grade A tertiary hospital in Jiangsu Province. Methods:A total of 1 897 medical records under the quality control management receiv ing multi-dimension communication were enrolled in the experimental group,and a total of 1 189 medical records under the quality control management receiving solitary communication were enrolled as control group. the level A rate,level B rate and level C rate were recorded and compared between experimental group and control group. Results:The quality of medical records in the experimen tal group was significantly better than that in the control group evidently. Conclusions:With the improvement of four-level quality con trol system,the application of quality control by physicians is helpful to improve the four-level quality control system. Building the twoway feedback mechanism and multi-dimension communication channels are beneficial for inspiring the participation of clinical doc tors,which could improve the quality of medical records.

关 键 词：管理沟通 病案质控 病案质量 

分 类 号：R197[医药卫生—卫生事业管理]