三级质控法在病历书写质量控制中的应用  

The Application of Three-level Quality Control Method in theQuality Control of Medical Record Writing

作　　者：卜大宇 李冰[1] 李娜[1] 张济洲 李晨磊 Bu Dayu;Li Bing;Li Na;Zhang Jizhou;Li Chenlei(Beijing You'an Hospital Affiliated to Capital Medical University,Beijing 100069,China;不详)

机构地区：[1]首都医科大学附属北京佑安医院,北京市100069

出　　处：《中国病案》2020年第11期23-25,共3页Chinese Medical Record

摘　　要：目的探讨三级质控法在病历书写质量控制中的应用效果。方法收集2019年1月1日-2019年6月30日560份病案,按随机数字表法分为对照组和观察组各280例。对照组采用常规管理,观察组采用三级质控法。比较2组病案合格率、病案缺陷发生率和病案质量评分。结果观察组病案合格率98.57%(276/280)高于对照组90.71%(254/280)(P<0.05)。观察组病案评分为(93.12±1.56)分,对照组为(88.50±1.14)分;观察组病案质量评分高于对照组(P<0.05)。观察组病案缺陷发生率6.07%(17/280)低于对照组10.71%(30/280)(P<0.05)。结论三级质控法在病历书写质量控制中的应用效果较好,能提高病案质量。Objective To explore the application effect of the three-level quality control method in the quality control of medical record writing.Methods 560 cases from January 2019 to June 2019 were collected and divided into a control group and an observation group according to the random number table,280 cases each.The control group adopted routine management,and the observation group adopted three-level quality control method.The two groups’medical record qualification rate,medical record quality,incidence of medical record defects and medical record score were compared.62 medical staff in our hospital during the same period were selected to investigate the score of occupational burnout before and after the implementation of the three-level quality control method combined with the psychological contract method.Results The qualified rate of medical records in the observation group 98.57%(276/280)was higher than that in the control group 90.71%(254/280)(P<0.05).The medical record score of the observation group was(93.12±1.56)points,and that of the control group was(88.50±1.14)points;the medical record score of the observation group was higher than that of the control group(P<0.05).The incidence of medical record defects in the observation group 6.07%(17/280)was lower than that in the control group 10.71%(30/280)(P<0.05).After treatment,the medical staff’s emotional failure,low personal accomplishment,and emotional alienation scores were lower than before treatment(P<0.05).Conclusions The three-level quality control method had a good application effect in the quality control of medical record writing,improved the quality of medical records.

关 键 词：病历书写 病案质量 三级质控法 病案质量评分 病案缺陷 

分 类 号：R197.323[医药卫生—卫生事业管理]