新型冠状病毒肺炎疑似患者住院病案及发热门诊病案的管控  

Medical Records Management and Quality Control of Suspected Cases of COVID-19 from Inpatient Department and Outpatients

作　　者：郭妮 李建民 梁艺 杜伟 刘昕 赵利洁 卢春叶 Guo Ni;Li Jianming;Liang Yi;Du Wei;Liu Xin;Zhao Lijie;Lu Chunye(The Third Affiliated Hospital of Guangxi Medical University,Nanning 530031,Guangxi Zhuang Autonomous region,China;不详)

机构地区：[1]广西医科大学第三附属医院(南宁市第二人民医院),广西壮族自治区南宁市530031

出　　处：《中国病案》2020年第12期16-18,共3页Chinese Medical Record

摘　　要：目的通过对新型冠状病毒肺炎疑似患者住院病案和发热门诊病案进行质控前后的对比分析,探讨疫情防控对策。方法通过医院HIS系统分别选取2020年1月28日-2020年2月10日期间的89份新型冠状病毒肺炎疑似患者住院电子病历、325份发热门诊电子病历为质控前组;2020年2月11日-2020年2月28日期间的90份新型冠状病毒肺炎疑似患者住院电子病历、325份发热门诊电子病历为质控后组。通过对两组病历书写记录缺陷率进行质控前后对比分析,评价病案质控对提高疫情病历书写质量的影响作用。结果新型冠状病毒肺炎疑似患者住院电子病历的缺陷率由督查前69.92%下降至7.78%;发热门诊电子病历缺陷率由督查前71.38%下降至7.48%,差异均有统计学意义,P<0.05。结论规范正确的书写疫情期间电子病历,医院病案质控部门加强质量监管,是提高病案质量,防止疫情在医院内扩散,确保疫情防控目标实现的重要措施之一。Objective To explore epidemic prevention and control countermeasures by comparing and analyzing medical records of suspected cases of COVID-19 from inpatient department and outpatients from fever clinic before and after quality control.Methods We used HIS to select electronic medical records of 89 suspected cases of COVID-19 from inpatient department and 325 outpatients from fever clinic from Jan.282020 to Feb.102020 which were included into the non-quality control group,in the same way electronic medical records of 90 suspected cases of COVID-19 from inpatient department and 325 outpatients from fever clinic from Feb.112020 to Feb.282020 were included into the quality control group.Through comparing and analyzing the writing defect rate of medical records between the non-quality control group and the quality control group,the impact of medical record quality control on improving the writing quality of medical records amid epidemic was assessed.Results The defect rate of electronic medical records of suspected cases of COVID-19 from inpatient department was reduced from 69.92%before inspection to 7.78%,and the defect rate of electronic medical records of outpatients from fever clinic was reduced from 71.38%before inspection to 7.48%,the statistical differences were significant(P<0.05).Conclusions Writing standard and correct medical records amid epidemic and strengthening quality supervision through medical record quality control department in hospital is one of the important measures to improve the quality of medical records and prevent the spread of epidemic in hospital as well as to achieve epidemic prevention and control.

关 键 词：新型冠状病毒肺炎 疑似 住院病案 门诊病案 质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]