某院2018年21096份病案质量分析  

Quality Analysis of 21096 Cases of Medical Records in a Hospital in 2018

作　　者：王志娟 王美江 姜英姿 岳丽娟 Wang Zhijuan;Wang Meijiang;Jiang Yingzi;Yue Lijuan(Department of Renal Endocrinology,Weihai Branch of 970th Hospital of the PLA,Shandong Province,Weihai 264200,China)

机构地区：[1]解放军第970医院威海院区肾脏内分泌科,山东省威海市264200 [2]解放军第970医院威海院区信息科,山东省威海市264200

出　　处：《中国病案》2019年第11期3-5,共3页Chinese Medical Record

摘　　要：目的了解医院病案质量的总体情况,从而挖掘缺陷原因、制定整改对策、提升病案质量,助推医院医疗水平和服务水平的提高。方法对2018年1月-2018年12月的21096份病案进行终末质控,对照评分标准赋分后录入到电子病历系统,导出总体结果到Excel表中,对结果进行总结、分析、归纳。结果全年出院病案中缺陷病案4068份,总缺陷率19.28%,缺陷5146项,平均每份1.26个错误,其中病案首页缺项1985项,占总缺项的38.57%,单项否决病案267份,占总缺陷的5.19%。结论缺陷项主要集中在病案首页、病程记录、术前出院小结、各类知情同意书和谈话记录签字确认不规范上,病案质量制约着医院医疗质量和服务水平,必须持续改进和提高病案质量。Objectives To understand the overall situation of the quality of medical records of the hospital,so as to explore the causes of defects,formulate rectification measures,improve the quality of medical records,and promote the improvement of the medical level and service level of the hospital.Methods 21,096 medical records in the whole year of 2018 were subject to final quality control.After assigning the scores according to the scoring standards,the records were input into the electronic medical record system.The overall results were exported to Excel,and the results were summarized,analyzed and concluded.Results There were 4,068 defective medical records,with a total defect rate of 19.28%and 5,146 defects,with an average of 1.26 errors in each.Among them,there were 1985 missing medical records,accounting for 38.57%of the total missing medical records,and 267 rejected medical records,accounting for 5.19%of the total defects.Conclusions The defects were mainly concentrated in the front page of medical records,course records,preoperative discharge summary,all kinds of informed consent and interview record signing confirmation are not standard.Medical record quality restricts the medical quality and service level of hospitals,and it is necessary to continuously improve and improve the quality of medical records.

关 键 词：病案质量 终末质控 现状分析 

分 类 号：R197.323[医药卫生—卫生事业管理]