门诊病历质量检查工作探索  

Practice of Quality Inspection of Outpatient Medical Records

作　　者：崔胜男 王怡 孙亚萍 周炯 Cui Shengnan;Wang Yi;Sun Yaping;Zhou Jiong(Department of Medical Records,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences,Beijing 100730,China)

机构地区：[1]中国医学科学院北京协和医院病案科,北京市100730

出　　处：《中国病案》2021年第4期17-19,共3页Chinese Medical Record

基　　金：中央高校基本科研业务费专项资金资助。

摘　　要：门诊病历质量至关重要。参考已有病历书写规定,制定门诊初诊病历各项目的书写要求,设置单项否决项,经专家讨论确定门诊病历质量检查标准;建立"医师-科室-医院"三级质控体系,组建院级门诊病历内涵质控专家组,增加科室自查环节,对门诊病历质量进行多层级评价和监测;制定了从病历抽取、质控软件准备到结果统计反馈的一系列工作流程,质控结果经过专家例会讨论后院内公示,最终与科室绩效挂钩。随着质控工作的开展,门诊病历质量的优良率提升13.2%,差评率下降8.9%。但仍存在一定的问题,将在质控深度、质控范围、质控标准统一和智能质控方面进一步完善。The quality of outpatient medical records is very important. According to the existing medical record writing requirements, the experts discussed and formulated the writing requirements of each item of the outpatient medical record and the single veto. The three-level quality control system and the hospital level quality control expert group was established.A series of work processes from medical record extraction, quality control software preparation to results statistical feedback were developed. The quality control results were announced in the hospital, and finally linked to the department performance. As a result, the good rate of outpatient medical record quality increased by 13.2%, and the negative evaluation rate decreased by 8.9%. However, there are still certain problems, which will be further improved in terms of quality control depth, quality control scope, uniform quality control standards and intelligent quality control.

关 键 词：门诊病历 质量检查 质控体系 标准制定 

分 类 号：R197.323[医药卫生—卫生事业管理]