术前讨论制度执行情况调查与思考  

Investigation and Reflection on Implementation Status of Preoperative Discussion System

作　　者：张彦 林敏 杨静 袁玲玲 ZHANG Yan;LIN Min;YANG Jing(The 920th Hospital of the Joint Logistics Support Force,PLA,Kunming,Yunnan,650032,China;不详)

机构地区：[1]联勤保障部队第920医院质量管理科,云南昆明650032 [2]联勤保障部队第920医院,云南昆明650032

出　　处：《中国卫生质量管理》2020年第3期34-37,共4页Chinese Health Quality Management

摘　　要：目的了解术前讨论制度执行情况,针对性改进。方法采用回顾性调查方法,随机抽取某三级医院2019年3月出院的192例手术患者病历进行调查。采用Excel表格录入数据,SPSS 13.0软件进行统计分析。结果192例住院手术患者共实施手术198台次,术前讨论实施率100.00%。讨论主持人为科主任、主任医师(或副主任医师)占98.99%。术前讨论日期距入院日期平均(3.0±2.9)天,中位数2天。99.50%的术前讨论在手术前3天内完成。部分术前讨论记录存在记录不规范、讨论不充分等问题。结论医院应进一步规范术前讨论实施细则,明确要求,加大检查监督力度,利用信息化技术提高术前讨论记录电子病历模板的结构化水平和自动监控水平。Objective To investigate the implementation status of preoperative discussion system for targeted improvement.Methods A retrospective investigation was conducted to randomly select the medical records of 192 surgical patients discharged from a tertiary hospital in March 2019.The Excel table was used to input data,SPSS13.0 software was used for statistical analysis.Results A total of 198 operations were performed among the 192 surgical inpatients,and the preoperative discussion rate was 100.00%.98.99% of the discussion hosts were chaired by department directors or chief physicians(or vice-chief physicians).The mean preoperative discussion date was(3.03±2.86)days from the admission date,with a median of 2 days.99.50% of the preoperative discussions were completed within 3 days before operation.Some of the preoperative discussion records were not standardized and insufficient.Conclusion The hospital should further standardize the implementation rules of preoperative discussion,specify the requirements,strengthen the inspection and supervision,and use information technology to improve the structural level and automatic monitoring level of the electronic medical record template for preoperative discussion and recording.

关 键 词：医疗质量 术前讨论制度 执行情况 

分 类 号：R197.31[医药卫生—卫生事业管理]