某县级三甲中医院终末病案现状分析  

Analysis on the Current Status of the Terminal Medical Records in a County-level Three A and Tertiary TCM Hospital

作　　者：张盼盼 Zhang Panpan(Taihe Hospital Affiliated Anhui College of Traditional Chinese Medicine,Taihe 236607,Anhui Province,China)

机构地区：[1]安徽中医药大学附属太和中医院质控办,安徽省太和县236607

出　　处：《中国病案》2021年第3期14-16,共3页Chinese Medical Record

摘　　要：目的了解某县级三甲中医院终末病案现状,分析存在问题和可能原因,为制定行之有效的干预措施提供依据。方法病案室抽取2019年4月1日-2019年12月31日期间1065份终末病案,16位同时具有研究生学历和主治及以上职称医师,依据安徽省病案质量评定标准(试行),逐份记录每份病案存在问题和等级,用Excel 2007对各临床科室病案质控结果进行录入和统计,采用回顾性分析方法对统计结果进行描述性分析。结果病案甲级率为94.74%,合格率为98.22%。入院记录问题存在率最高为26.09%,其次是病程记录为23.23%,病案首页为19.68%。骨科丙级病案占比最高为47.37%,其次是外科为21.05%;骨科乙级病案占比最高为40.54%,其次是外科为16.22%。结论终末病案质量达到安徽省病案质量综合评定甲级率≧90%的要求,但内涵质量仍需提高,各科室病案质量参差不齐,尤其应加强手术科室病案质量管理。Objectives To understand the current status of terminal medical records in a county-level Three A and Tertiary hospital of traditional Chinese medicine,analyze the existing problems and possible causes,and provide a basis for formulating effective intervention measures.Methods The medical record room selected 1065 terminal medical records from April 1st,2019 to December 31st,2019,and 16 doctors with both a postgraduate degree and a professional title of attending or above.According to the Medical Record Quality Evaluation Standard of Anhui Province(Trial),one by one record the problems and grades of each medical record,use Excel 2007 to enter and count the quality control results of each clinical department,and use retrospective analysis methods to perform descriptive analysis of the statistical results.Results The medical record grade A rate was 94.74%,and the pass rate was 98.22%.The incidence of problems with admission records was the highest(26.09%),followed by records of the course of illness(23.23%),and the front page of medical records(19.68%).Orthopedics Grade C medical records accounted for the highest proportion(47.37%),followed by surgery(21.05%);Orthopedics Grade B medical records accounted for the highest proportion(40.54%),followed by surgery(16.22%).Conclusions The quality of terminal medical records meets the requirements of the comprehensive assessment of medical record quality in Anhui Province with a grade A rate of≥90%,but the quality of connotation still needed to be improved.The quality of medical records varied from department to department.In particular,the quality management of medical records in operating departments should be strengthened.

关 键 词：县级 三甲中医院 终末病案 现状分析 

分 类 号：R197.323[医药卫生—卫生事业管理]