实名点评结合奖惩制度在骨科运行病历质量管理中的应用  

Application of Real Name Comment combined with Reward and Punishment System in the Quality Management of Orthopedic Running Medical Records

作　　者：胡朝阳[1] 钟阳 侯大香 罗华凤 马刚[1] 何欣宇 Hu Chaoyang;Zhong Yang;Hou Daxiang;Luo Huafeng;Ma Gang;HeXinyu(The General Hospital of Pangang Group,Panzhihua 617000,Sichuan Province,China;不详)

机构地区：[1]攀钢集团总医院,四川省攀枝花市617000

出　　处：《中国病案》2022年第5期7-8,21,共3页Chinese Medical Record

摘　　要：目的 实施实名点评结合奖惩制度的方法,提高骨科运行病历质量。方法 随机抽查2018年6月1日-12月31日360份运行病历为对照组,2019年6月1日-12月31日360份运行病历为观察组,2019年1月1日开始采用实名点评、奖惩方式,对运行病历质量持续性改进6个月,比较实名点评前后的运行病历质量。结果 对照组与观察组甲级病历数分别为265份(73.6%)和310份(86.1%),乙级病历数分别为82份(22.8%)和47份(13.1%),丙级病历13份(3.6%)和3份(0.8%),差异均具有统计学意义。对照组与观察组病历平均分分别为(83.6±6.5)分和(90.8±4.2)分,差异具有统计学意义。结论 采用实名点评、奖惩方式对骨科运行病历进行持续性改进,可显著提高病历质量。Objectives To improve the quality of orthopedic medical records by practicing the method of real name comment combined with reward and punishment system.Methods 360 running medical records from June 1st,2018 to December 31th,2018 were randomly selected as the control group and 360 running medical records from June 1st,2019 to December 31th,2019 as the observation group.The quality of running medical records was continuously improved for 6 months by means of real name comment,reward and punishment,and the quality of running medical records before and after real name comment was compared.Results There were 265(73.6%) and 310(86.1%) grade a medical records,82(22.8%) and 47(13.1%) grade B medical records,13(3.6%) and 3(0.8%) grade C medical records in the control group and the observation group,respectively,and the differences were statistically significant.The average scores of medical records in the control group and the observation group were(83.6±6.5) and(90.8±4.2),the difference was statistically significant.Conclusions The continuous improvement of orthopedic running medical records by real name comment,reward and punishment could significantly improve the quality of medical records.

关 键 词：实名点评 运行病历 质量管理 

分 类 号：R197.323[医药卫生—卫生事业管理]