7655份归档病历缺陷统计分析及质控效果评价  

Statistical Analysis and Quality Control Effect Evaluation of 7655 Archived Medical Records

作　　者：张兵[1] ZHANG Bing(Department of Medical Affairs,People's Hospital of Sheyang County,Yancheng,Jiangsu Province,224300 China)

机构地区：[1]射阳县人民医院医务科,江苏盐城224300

出　　处：《中国卫生产业》2021年第19期162-165,共4页China Health Industry

摘　　要：目的通过分析该院近6年来归档病历存在的缺陷,改善质控模式,加大奖惩力度,从而提高病历质量。方法把江苏省卫生健康委员会修订的《病历书写规范(第2版)》中制定的《江苏省住院病历质量评定标准》作为评分标准,把《射阳县人民医院病历质量管理暂行规定》作为奖惩标准,收集该院6年间随机抽查的7655份归档病历,采用终末病案质量控制的方法进行缺陷总结和分析。结果通过6年的努力,该院乙级病历和丙级病历数量明显下降,近6年来乙、丙级病历数量变化趋势来看,该院归档病历乙级和丙级数量显著下降,甲级病历率逐年提升,从2015年的92.3%提升到2020年的98.7%,提高了6.4个百分点。结论加大对归档病历的质控和奖惩力度,从医师的质控观念抓起,不断提高质控人员的整体素质,可以逐步提升全院病历书写质量。Objective To improve the quality of medical records by analyzing the defects in the archived medical records of the hospital in the past 6 years,improving the quality control model,and increasing the amount of awards and punishments.Methods The"Jiangsu Provincial Hospitalized Medical Record Quality Evaluation Standards"formulated in the"Medical Record Writing Standards(Second Edition)"revised by the Jiangsu Provincial Health Commission was used as the scoring standard,and the"Interim Provisions on the Quality Management of Medical Records in Sheyang County People's Hospital"as rewards and punishments standard,to collect 7655 archived medical records randomly checked in the hospital during 6 years,and use the method of final medical record quality control to summarize and analyze the defects.Results After 6 years of hard work,the number of grade B and grade C medical records in the hospital has dropped significantly.In the past 6 years,the number of grade B and C medical records has changed significantly.The rate has increased year by year,from 92.3%in 2015 to 98.7%in 2020,an increase of 6.4 percentage points.Conclusion Increasing the quality control,rewards and punishments of archived medical records,starting from the doctor's quality control concept,and continuously improving the overall quality of the quality control staff,can gradually improve the quality of the hospital's medical records.

关 键 词：病历 病历缺陷 质量控制 效果评价 

分 类 号：R19[医药卫生—卫生事业管理]