2015年-2019年精神科病案质量影响因素分析  

Investigation on the Situations and Influencing Factors of Medical Records Quality in Psychiatry Department from 2015 to 2019

作　　者：尹定富 冯勇 曹秀英[1] 魏星 Yin Dingfu;Feng Yong;Cao Xiuying;Wei Xing(Department of Psychiatry,Huangshi Psychiatric Hospital,Huangshi 435004,Hubei Province,China;不详)

机构地区：[1]黄石市精神病医院精神科,湖北省黄石市435004

出　　处：《中国病案》2021年第7期12-15,共4页Chinese Medical Record

摘　　要：目的调查某院2015年-2019年精神科病案质量,分析影响因素,为指导临床精神科病案质量提升提供依据。方法采用多阶段分层群体随机抽样方法抽取2015年1月1日-2019年12月31日每年150份,共计750份精神科病案资料,对每份病案进行质量评级,分析精神科病案质量情况,通过Logistic回归分析筛选主要影响因素。结果抽取的750份病案中,Ⅰ级合格病案共有595份,Ⅰ级、Ⅱ级、Ⅲ级、Ⅳ级病案质量等级各占79.33%、16.53%、3.47%、0.67%;2017年-2019年Ⅰ级合格病案比例86.22%高于2015年-2016年69%(P<0.05);750份病案中共查出缺陷项目数923项,其中病案首页缺陷、病程记录缺陷、书写基本要求分别占比32.94%、26%、24.38%高于入院记录、知情同意书、辅助检查、出院记录10.83%、1.41%、2.38%、2.06%(P<0.05);Logisitic回归分析显示住院医师为男性、患者住院天数长是导致病案质量不合格的独立危险因素,住院医师年龄较大、职称较高是病案质量合格的因素。结论2017年-2019年病案质量优于2015年-2016年,病案缺陷主要表现在病案首页缺陷、病程记录缺陷、书写基本要求,住院医师性别、年龄、职称以及患者住院天数均影响病案质量水平。Objectives To investigate the quality of medical records in psychiatry department of the hospital from 2015 to 2019 and analyze its influencing factors, so as to provide basis for clinically guiding the improvement of medical records quality. Methods A total of 750 copies of psychiatric medical records data(150 copies each year) from January 1 st, 2015 to December 31 st, 2019 were collected by multi-stage and stratified random sampling method. Quality rating of each medical record was conducted to analyze medical records quality in psychiatry department. And the main influencing factors were screened out by Logistic Regression analysis. Results Among the 750 copies of medical records, there were 595 copies of grade-Ⅰ qualified medical records. The proportions of grade Ⅰ, Ⅱ, Ⅲ and Ⅴ medical records were 79.33%, 16.53%, 3.47% and 0.67%, respectively. The proportion of grade-Ⅰ qualified medical records in 2017 to 2019 was higher than that in 2015 to 2016(86.22% vs 69.00%)(P<0.05). Among the 750 copies of medical records, there were 923 defective items. The proportions of homepage defects of medical records, defects in medical records and basic writing requirements were 32.94%, 26.00% and 24.38%, higher than those of admission records, informed consent, auxiliary examination, and discharge records defects(10.83%, 1.41%, 2.38%, 2.06%)(P<0.05). Logistic regression analysis showed that male resident doctor and long hospitalization time were independent risk factors of unqualified medical records, while elderly resident doctor and high-level professional title were the protective factors. Conclusions The quality of medical records from 2017 to 2019 was better than that from 2015 to 2016. The defects of medical records mainly included front page defects of medical records, defects in medical records recording and basic writing requirements. The gender, age and professional title of resident doctors, and hospitalization time of patients all affected the quality of medical records.

关 键 词：精神科 病案质量 现状调查 影响因素 

分 类 号：R197.323[医药卫生—卫生事业管理]