11113份终末病案质量缺陷分析及对策  

Analysis and Countermeasure of 11113 Cases of Terminal Defects

作　　者：滕方 孙启荻 周玲玲 陈洪 Teng Fang;Sun Qidi;Zhou Lingling;Chen Hong(of Quality Management,Army Special Medical Center,Chongqing 400042,China;不详)

机构地区：[1]陆军特色医学中心质量管理科,重庆市400042 [2]陆军特色医学中心医研部,重庆市400042 [3]陆军特色医学中心信息资料科,重庆市400042

出　　处：《中国病案》2020年第11期16-19,共4页Chinese Medical Record

基　　金：中心人才创新能力培养计划(2019CXLCC008)。

摘　　要：目的探讨影响终末病案质量缺陷的关键因素和改进措施。方法抽取2019年1月1日-2019年11月30日11113份终末病案,统计分析质量缺陷;结果11113份终末病案中有3449份病案存在缺陷,缺陷率为31.04%,其中手术科室缺陷率明显高于非手术科室。缺陷项目共5034项,常见的缺陷项目主要是缺授权委托书或内容缺陷占21.65%、各级医师未签名占14.35%、缺身份证明或自费签字证明占12.57%、病程记录中未反映会诊意见及处理情况占9.14%和入院记录生命体征或查体记录缺陷占6.20%;结论通过采取各种措施,对手术和非手术科室开展专项质控,分析病历书写中缺陷问题的共性与差异,逐步降低缺陷率,促进病案内涵质量不断提高。Objectives The dissertation aims to find out the critical factors related to the medical records quality and its countermeasures.Methods A random sample of 11113 medical records in Clinical department from Januaryto November in 2019 was selected for further statistical analysis.Results Among the 11113 final cases,3449 cases were found defective with a defect rate of 31.04%,and the case defect rate of surgical departments was significantly higher than that of non-surgical departments.There were 5034 defective items in total,whose defective ratios ranking from high to low were:21.65%(no letter of authorization or content defective),14.35%(no signature of related physicians),12.57%(no identification or self-paying-related signature),9.14%(no consultation results or treatment suggestion in progress notes),6.20%(no life vital signs recording or physical examination recording in admission records).Conclusions Effective countermeasures should be taken to analyze the similarities and differences in medical records writing so as to carry out special quality.Thus a gradual decreasing of defect rate and a sustainable quality improvement were expected.

关 键 词：终末病案 质量缺陷 分析 

分 类 号：R197.323[医药卫生—卫生事业管理]