追踪方法学在病案管理工作质量持续改进中的应用  

Application of Tracking Methodology in Continuous Improvement of Medical Record Management Work Quality

作　　者：冷冬梅[1] LENG Dong-mei(Medical Record Room,Linyi Hospital of Traditional Chinese Medicine,Linyi,Shandong Province,276002 China)

机构地区：[1]临沂市中医医院病案室,山东临沂276002

出　　处：《中国卫生产业》2020年第22期7-9,共3页China Health Industry

摘　　要：目的探析追踪方法学在病案管理工作质量持续改进中的应用效果。方法选取该院2017年1—8月收集的1000份病案作为研究对象,均分为两组,对照组和研究组,每组500份,对照组采取传统的病案管理方法,研究组于2017年8月组建病案管理小组,运用追踪方法学对管理各个环节进行追踪研究,首先在系统上查找流程中的不足和缺陷,经过小组讨论,对系统流程进行全面评估和分析,对于出现的不足之处进行整改和优化,做到完善体系,提高工作质量的效果。结果与对照组相比,研究组出院病案3 d内的回收率(98.0%)、ICD编码准确率(97.2%)均有显著提高,病案首页缺陷率(3.0%)明显下降,组间差异有统计学意义(P<0.05)。结论应用追踪方法学能够有效规避病案管理工作中各环节的缺陷,在持续改进病案管理工作质量中发挥重要作用。Objective To analyze the application effect of tracking methodology in the continuous improvement of the quality of medical record management.Methods 1000 medical records collected in the hospital from January to August 2017 were selected as the research objects,and they were divided into two groups,a control group and a study group,each with 500 cases.The control group adopted traditional medical record management methods,and the study group adopted medical record management team was established in August 2017 to use tracking methodology to track and study all aspects of management.First,find the deficiencies and defects in the process on the system.After group discussion,the system process was comprehensively evaluated and analyzed.The deficiencies should be rectified and optimized to improve the system and improve the quality of work.Results Compared with the control group,the recovery rate(98.0%)and ICD coding accuracy(97.2%)of medical records within 3 d of discharge in the study group were significantly improved,and the defect rate of the first page of medical records(3.0%)was significantly reduced,and the difference between the two groups were statistically significant(P<0.05).Conclusion The application of tracking methodology can effectively avoid the defects in all aspects of medical record management and play an important role in continuously improving the quality of medical record management.

关 键 词：追踪方法学 病案管理 工作质量 应用 

分 类 号：R197[医药卫生—卫生事业管理]