影响住院医师病案首页填写质量的因素分析及对策  被引量:7

The filling quality of the first page of medical records of residents:Influencing factors and countermeasures

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作  者:牟怡平[1] 彭蓉[1] 王瑞涛[1] MU Yiping;PENG Rong;WANG Ruitao(Medical Information Management Office,the First Affiliated Hospital of Xi'an Jiaotong University,Shaanxi,Xi'an 710061,China)

机构地区:[1]西安交通大学第一附属医院医疗信息管理办公室,陕西西安710061

出  处:《中国医药科学》2020年第12期174-177,共4页China Medicine And Pharmacy

基  金:西安交通大学科研基金软科学项目(2015YK36)。

摘  要:目的总结分析住院病案首页填写的影响因素并提出相应对策。方法根据某院2018年6~12月随机抽查的1890份住院病案首页填写质量,采用问卷法并引入非条件Logistic回归中进行多因素分析,分析影响住院医师病案首页填写质量的相关因素。结果影响住院医师病案首页填写质量的主要因素为已工作时间、接受病案首页质控及相关培训状况。结论加强病案首页填写培训、提升信息化质控能力、提高医院管理部门重视程度等措施可以提高病案首页填写质量。Objective To summarize and analyze the influencing factors of filling quality of the first page of medical records and propose corresponding countermeasures.Methods A total of 1890 inpatient medical records were randomly selected from June to December 2018 in a hospital and their filling quality was analyzed using a questionnaire method and introducing the non-conditional Logistic regression to perform multivariate analysis,and the relevant factors affecting the quality of the resident medical records’first page filling were analyzed.Results The main factors affecting the quality of filling in the first page of medical records of residents were working years and the acceptance of quality control of the first page of medical records and related training.Conclusion The quality of filling in the first page of medical records can be improved by strengthening the training of filling,improving the quality of information-based quality control,and emphasizing the importance of hospital management departments,etc.

关 键 词:住院医师 病案首页质量 影响因素 病案首页填写 

分 类 号:R197.3[医药卫生—卫生事业管理]

 

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