改善某三甲医院儿科脑电图报告的及时归档  

Improvement of Timely Filing of Pediatric EEG Reports in a Three A and Tertiary Hospital

作　　者：黄昊[1] Huang Hao(Xuanwu Hospital Affiliated to Capital Medical University,Beijing 100053,China)

机构地区：[1]首都医科大学宣武医院,北京市100053

出　　处：《中国病案》2022年第6期9-12,共4页Chinese Medical Record

摘　　要：目的 通过调查儿科脑电图辅助检查报告单的归档延迟的原因,进行流程改进的干预措施,比较干预前后的出院患者病案归档完整率,以观察干预的效果。方法 采用方便抽样调取2021年3月1日-2021年8月31日儿科一日病房癫痫患儿病案资料,共214例。分为干预前、干预中、干预后三组观察归档完整率变化情况。结果 是否及时(7日)归档的干预前、干预中、干预后的患者例数分布差异有统计学意义(Z=-12.972,P<0.05),归档完整率在干预前、干预中、干预后分别为0%、27.45%和100%。流程改进之后,患者可以尽早得到脑电图结果复印件,比干预前至少提前15天。结论 通过干预病案的辅助检查报告的归档流程,提升了脑电图归档率并减少了患者无效等待时间。Objectives To investigate the causes of slow filing of pediatric EEG auxiliary examination report forms,carry out intervention measures to improve the process,and compare the rate of complete filing of medical records of discharged patients before and after intervention,so as to observe the effect of intervention.Methods Convenient sampling was used to collect the medical records of 214 children with epilepsy from March 1st,2021 to August 31st,2021.The archival integrity rate was divided into three groups:before intervention,during intervention and after intervention.Results There were statistically significant differences in the distribution of cases before,during and after intervention(Z=-12.972,P<0.05).The rate of archiving integrity before,during and after intervention was 0%,27.45% and 100%,respectively.With improved procedures,patients can get copies of EEG results as early as possible,at least 15 days before intervention.Conclusions It could improve the rate of EEG filing and reduce invalid waiting time of patients by intervening in the filing process of auxiliary examination report of medical records.

关 键 词：归档完整率 流程改进 干预 病案质量 病案管理 

分 类 号：R197.323[医药卫生—卫生事业管理]