临床医生质控员病历质量质控大赛结果分析与改进措施  

Analysis of the results of the quality control contest for medical records by clinical doctors as quality controllers

作　　者：唐瑶 李凌[1] 尹龙燕[1] 邓杰芳[1] TANG Yao;LI Ling;YIN Longyan;DENG Jiefang(Guangzhou First People's Hospital,Guangzhou 510180,China)

机构地区：[1]广州市第一人民医院,广东广州510180

出　　处：《现代医院》2020年第5期679-681,685,共4页Modern Hospitals

摘　　要：目的举行临床医生质控员病历质量质控大赛,了解其病历质量控制的现况,探寻提高病历质控水平、提高病历质量的有效途径。方法采用参考《广东省病历书写与管理规范》而自行编制的《病案质控实操试卷》对医院各临床科室质控员进行考核,考核内容分为理论考试与病历质控实际操作。对考核成绩建立数据库并进行比较分析。结果参加考核的质控员有61人,平均分为69. 5分,最高分93分。理论考试中错误率最高的为对病历书写时限性把握,达44. 26%~73. 77%;病历质控实际操作中首页及入院记录主要诊断选择错误、遗漏诊断、首次病程记录超时、缺输血病程记录等问题回答得比较好,未检出率为17. 74%~38. 71%;而首页操作未填写、未发现离院方式错误、内容记录简单、矛盾、遗漏、复制粘贴等问题未检出率较高,为45. 16%~90. 16%。结论临床质控员对于主要诊断的选择及一些一票否决的乙级缺陷把握得比较好,对病程记录书写的细节问题、时限性问题关注不足,对于病历书写内容的质量控制仍需要加强学习。有必要进一步加强人员管理、技能培训,提高质控员的病历书写质控水平,从而有效提高全院病历书写质量。Objective To understand the mindset of the quality control of the medical records and explore the effective methods to enhance the expertise in quality of medical records through holding a contest of quality control of the medical records among clinical doctors as quality controllers. Methods The examination questions were based on Guandong Provincial Regulations on Medical Records Writing and Management. The examinees were quality controllers from various clinical departments. The assessment contents were divided into theoretical examination and practical operation of medical record quality control. Results There were 61 quality controllers attending the contest with an average score of 69. 5 and a maximum score of 93. The part with the highest most common error rate in the theoretical examination was the time limit of medical records writing,reading 44. 26%-73. 77%. In the practical operation session,the questions best answered were the front page,the admission records( the major diagnosis,first record,blood infusion record,etc..) with undetected error rate between 17. 74%-38. 71%. The questions not answered well were front page with no operation procedures,discharge record,contents with much simplification or with contradiction,omission,and copying-and-pasting,reaching 45. 16%-90. 16%. Conclusion The clinical doctors as the quality controllers have a good understanding of major diagnosis and type B errors for veto,but they pay no enough attention to the record details and time limits. So they need to attach importance to the quality control over the record writing quality. It is needed to enhance personnel management,technical training and quality control to improve the quality of medical records writing.

关 键 词：质控员 病历质量 措施 

分 类 号：R197.323.4[医药卫生—卫生事业管理]