基于现状调查分析为基础的闭环式病历书写质控一体化模式的构建  

Construction of Integrated Quality Control Model for Closed-Loop Medical Record Writing Based on Status Survey Analysis

作　　者：于燕平[1] 郝晓丽[1] 陈文梅[1] 许振东[1] 荆友斌[1] 刘金旭[1] 张建锐 YU Yan-ping;HAO Xiao-li;CHEN Wen-mei;XU Zhen-dong;JING You-bin;LIU Jin-xu;ZHANG Jian-rui(Pingdu People's Hospital of Qingdao,Qingdao,Shandong Province,266700 China)

机构地区：[1]青岛平度市人民医院,山东青岛266700

出　　处：《中国卫生产业》2020年第11期185-187,共3页China Health Industry

摘　　要：目的对目前运行病历的书写状况进行调查,探讨建立有效的病历质控体系。方法于2018年5-8月对3家三级医院内外科各5个科室住院医师100名采用问卷调查。结果目前运行病历存在问题为各科室未完全按照病案书写规范(55%)、未完全参照病案书写规范建立科室模板(57%)、科室病历书写模板不具有同质性(84%),各科室病历模板建立之后未能按照病案书写规范(94%)与质控缺陷项目进行及时调整(74%)、科室对医院质控结果认同程度不高(61%),并从临床医师、病历质控人员、数据反馈与追踪等3个方面寻找原因,最终构建闭环式病历书写质控一体化模式。结论针对病历书写目前存在问题有建立的闭环式病历书写质控一体化模式的必要性,此模式可进一步进行效果分析,为判定其能否进行临床推广提供数据基础。Objective To investigate the writing status of current medical records and establish an effective medical record quality control system.Methods A questionnaire survey was conducted among 100 residents in 5 departments in 3 tertiary hospitals in May and August 2018.Results At present,there are problems in running medical records.Each department has not fully complied with the medical record writing specifications(55%).The department template has not been completely established according to the medical record writing specifications(57%).Departement case writing templates are not homogeneous(84%).After the establishment of the department's medical record template,it failed to make timely adjustments in accordance with the standard for writing medical records(94%)and quality control deficiencies(74%).The department did not agree with the hospital's quality control results(61%).Control personnel,data feedback and tracking to find the reasons,and finally build a closed-loop medical record writing quality control integration model.Conclusion For the existing problems of medical record writing,it is necessary to establish an integrated quality control model of closed-loop medical record writing.This model can further analyze the effects and provide a data basis for judging whether it can be clinically promoted.

关 键 词：病历书写 质控 模式 

分 类 号：R19[医药卫生—卫生事业管理]