某院三级查房考核质量分析  

Quality Analysis of Tertiary Ward Round Assessment in a Hospital

作　　者：杨廷龙 马玲 孙陶[1] 邢泽红 杨丽媛 冯娟[1] 冯琳 杨帆 何治平[1] 张炜[2] YANG Tinglong;MA Ling;SUN Tao(Second People’s Hospital of Shizuishan,Shizuishan,Ningxia,753000,China)

机构地区：[1]石嘴山市第二人民医院,宁夏石嘴山753000 [2]石嘴山市第二人民医院医务科,宁夏石嘴山753000

出　　处：《中国卫生质量管理》2021年第8期24-26,共3页Chinese Health Quality Management

摘　　要：目的了解三级查房中各级医师存在问题,提出改进策略。方法由7名具有高级职称的临床专家,按照统一评分标准进行观摩并打分,利用词云图分析存在问题。结果一级医师存在辅助检查解读不全面、疑难点报告不清晰、病历陈述缺项、查体手法不规范及查体前后未执行手卫生等问题;二级医师存在解答疑难问题不全面、临床思维讲解不透彻及查体纠正不到位等问题;三级医师存在对国内外最新知识进展讲解不全面及对查房内容点评不到位等问题。结论各级医师查房中都存在一定问题。医院管理者应针对不同级别医师提供个性化培训,促其努力提升医疗服务能力。同时,树立优秀科室榜样,充分发挥榜样带动作用。此外,还应充分利用人工智能技术辅助。Objective To investigate the problems of physicians at all levels of the tertiary ward round and to propose improvement strategy.Methods Seven clinical experts with senior professional titles observed and scored according to the unified scoring standards.Problems were analyzed by word cloud map.Results First-level physicians had problems such as incomplete interpretation of auxiliary examination,unclear report of difficult points,missing items in medical record statement,non-standard physical examination techniques and lack of hand hygiene before and after physical examination.Second-level physicians had problems such as incomprehensive answers to the difficult questions,unthorough explanation of clinical thinking and incomplete correction of physical examination.Third-level physicians had problems such as incomplete explanation of the latest knowledge progress at home and abroad and incomplete comment on the contents of ward rounds.Conclusion There were some problems in ward rounds by physicians at all levels.Hospital managers should provide personalized training for physicians of different levels to promote their efforts to improve their medical service ability.Furthermore,it should set up excellent department example,give full play to the role of example;and it can also make full use of artificial intelligence technology to assist.

关 键 词：医疗质量 医师 三级查房制度 考核 词云图 

分 类 号：R197.31[医药卫生—卫生事业管理] R197.32[医药卫生—公共卫生与预防医学]