某医院产科住院病案首页质量改进效果评价  

Improvement of the writing quality of first pages of obstetric inpatient medical records in a hospital

作　　者：刘骏峰[1] 袁燕 吴婷[1] 熊莺[1] LIU Junfeng;YUAN Yan;WU Ting;XIONG Ying(The First Affiliated Hospital of Sun Yat-sen University,Guangzhou 510080,China)

机构地区：[1]中山大学附属第一医院,广东广州510080

出　　处：《现代医院》2021年第11期1716-1718,1721,共4页Modern Hospitals

摘　　要：目的分析广州市某医院产科住院病案首页填写缺陷及产生的原因,并提出针对性改进措施,为产科病案管理工作提供参考依据。方法选取2020年7月1日—2020年10月31日该院实施干预措施前的产科住院病案629份作为干预前组,选取2020年11月1日—2021年2月28日该院实施干预措施后的产科住院病案920份作为干预后组。对病案首页抽检率、总体合格率、主要诊断、其他诊断和手术操作等指标的情况进行质控统计,并分析了病案首页问题分布情况。结果产科病案首页抽检率由42.79%提高至64.25%,差异有统计学意义(P<0.001)。总体合格率由94.59%提高至98.26%,差异有统计学意义(P<0.001)。主要诊断填写合格率由96.82%提高至98.70%,差异有统计学意义(P<0.05)。其他诊断填写合格率由98.25%提高至99.57%,差异有统计学意义(P<0.05)。手术操作填写合格率由99.36%提高至99.78%,差异没有统计学意义(P>0.05)。主要诊断选择最主要的问题是有并发症的产妇,主要诊断仍然选择妊娠分娩情况。结论产科住院病案存在一定的质量缺陷,通过加强住院病案首页培训、加强出院病案质量监测和完善电子病历质控系统功能等一系列改进措施,既可提高病案首页抽检率,又能够有效减少病案质量缺陷,进而提高病案首页质量。Objective To analyze the writing defects and its causes of the first page of obstetric inpatient records in a hospital in Guangzhou,and put forward the corresponding improvement measures so as to provide reference for the management of obstetric medical records.Methods A total of 629 cases of inpatient records from the obstetrics department before the intervention from July 1,2020 to October 31,2020 were selected as the pre-intervention group,and 920 cases of inpatient medical records from November 1,2020 to February 28,2021 were selected as the post-intervention group.The quality control statistics of sampling rate of the first pages,overall qualification rate,primary diagnosis,other diagnosis and surgical operation were carried out.The distribution of problems on the first pages of medical records was analyzed.Results The sampling rate of the first pages from the medical records increased from 42.79% to 64.25%,with statistically significant difference between the pre-and post-intervention(P<0.001).The overall qualified rate of the first page increased from 94.59% to 98.26%,with statistically significant difference(P<0.001).The qualification rate of primary diagnosis writing increased from 96.82% to 98.70%,with statistically significant difference(P<0.05);The qualification rate of writing other diagnoses on the first page increased from 98.25% to 99.57%,with statistically significant difference(P<0.05).The qualification rate of writing the surgical operation records increased from 99.36% to 99.78%,without statistically significant difference(P>0.05).In the choice of primary diagnosis were mistakes that the item of "Pregnancy and Delivery" was ticked for the pregnant women with complications.Conclusion There are some defects in the writing quality of obstetric inpatient medical records.Through a series of improvement measures,such as strengthening the training of filling the first page of inpatient medical records,enhancing the quality monitoring of discharge medical records and improving the function of quality

关 键 词：产科 病案首页 质量 评价 

分 类 号：R197.323.4[医药卫生—卫生事业管理]