临床督导员制在医院病案质控管理中的作用探讨  

Investigation on the Role of Clinical Supervisor System in the Medical Record Quality Control Management of a Hospital

作　　者：王明霞[1] 叶世岳[1] 郭顺萍[1] Wang Mingxia;Ye Shiyue;Guo Shunping(Department of Medical Records,The First Affiliated Hospital of Fujian Medical University,Fuzhou 350004,Fujian Province,China;不详)

机构地区：[1]福建医科大学附属第一医院,福建省福州市350004

出　　处：《中国病案》2022年第5期1-2,81,共3页Chinese Medical Record

基　　金：福建省卫生健康软科学研究课题(2021RKA004)。

摘　　要：目的 对比某三甲综合性医院实施临床督导员制前后医院病案质量的变化,探讨临床督导员制在病案质控管理中的作用。方法 采用回顾性研究根据临床督导员制实施情况分为实施前2019年4月1日-12月31日归档病案930例,其中非手术病案388例和手术病案542例;实施后2020年4月1日-12月31日归档病案1050例,其中非手术病案415例和手术病案635例,对比2组的病案质量总体情况、平均病案缺陷数、终末病案主要缺陷及占比情况。结果 无论是非手术科室还是手术科室,与实施前比较,实施后的病案甲级率均升高,病案乙级率均降低;非手术科室平均病案缺陷数由3.69减少至2.87,手术科室平均病案缺陷数由4.36减少至3.06;非手术科室及手术科室终末病案主要缺陷占比均不同程度降低,非手术科室病案日常病程记录缺陷占比从18.9%降低至15.7%,首次病程记录缺陷从18.8%降低至15.3%,病案首页缺陷占比从12%降低至8.1%;手术科室病案围手术期记录缺陷占比从24.9%降低至19.4%,上级医师首次查房记录从11.6%降低至9.3%;缺陷病案整改率由实施前的73.6%提高至91.7%。结论 实施临床督导员制用于病案质控管理,在病案质量提高方面发挥着积极作用。Objectives To investigate the role of clinical supervisor system in the medical record quality control management by comparing the changes of medical record quality before and after the implementation of clinical supervisor system in a Three A general Hospital.Methods According to the implementation of the clinical supervisor system based on retrospective study,the medical record were divided into two groups:before implementation group,from April 1st to December 31st in 2019,930 cases of medical records were filed,including 388 Cases of non-surgical medical records and 542 cases of surgical medical records;after implementation group,1050 cases of medical records were filed,including 415 cases of non-surgical medical records and 635 cases of surgical medical records;the overall quality situation,the average numbers of defects in medical records,the main defects in terminal medical records and its proportion were being compared between the two groups.Results No matter in the non-surgical departments or in the surgical departments,the A-Grade rate of medical records increased between before and after its execution,while the B-Grade rate of medical records decreased.The average number of medical record defects in non-surgical departments decreased from 3.69 to 2.87,and the average number of medical record defects in surgical departments decreased from 4.36 to 3.06;The proportion of main defects in the terminal medical records of non-surgical departments and surgical departments were both decreased.The proportion of defects in the daily disease course of medical records in non-surgical departments decreased from 18.9% to 15.7%,the defect in the first disease course record decreased from 18.8% to 15.3%,and the proportion of defects in the front page of medical records decreased from 12% to 8.1%.The proportion of defects in perioperative period of medical records in surgical departments decreased from 24.9% to 19.4%,the first ward round records of superior physicians decreased from 11.6% to 9.3%.The rectification rate o

关 键 词：临床督导员 病案质控管理 病案质量 

分 类 号：R197.323[医药卫生—卫生事业管理]