某三甲医院住院病案首页质控效果分析  

Analysis on the Effect of Quality Control on the First Page of Hospitalized Medical Records in a Third-Class Hospital

作　　者：饶柳珍 丁光霞[1] 陈珍初[1] Rao Liuzhen;Ding Guangxia;Chen Zhenchu(Yijishan Hospital Affiliated to Wannan Medical College,Wuhu 241000,Anhui Province,China;不详)

机构地区：[1]皖南医学院弋矶山医院,安徽省芜湖市241000

出　　处：《中国病案》2022年第4期17-19,共3页Chinese Medical Record

摘　　要：目的 评价某院住院病案首页质控体系改进后实施效果,提出改进措施,提高住院病案首页质量。方法 改进质控体系,调取2019年10月1日-12月31日住院病案首页质控数据和2020年10月1日-12月31日住院病案首页质控数据各1410份,统计住院病案首页缺陷数和缺陷率,采用χ^(2)检验进行分析,评价改进后效果。结果 改进质控体系后,外科病区住院病案首页基本信息、诊疗信息、住院信息填写缺陷率分别下降0.25%、0.16%、0.29%,内科病区下降0.08%、0.23%、0.09%;主要手术及操作名称、主要手术及操作级别、主要手术及操作Ⅰ助、主要手术及操作术者、主要手术及操作日期缺陷率下降0.55%、0.20%、0.19%、0.18%、0.15%,经χ^(2)检验,P<0.05,差异有统计学意义。结论 改进质控体系后,住院病案首页质量有所提升,但仍存在问题,还需加强专项质控、临床医师培训、信息化建设,落实考核,从而提高住院病案首页质量。Objective To evaluate the effect of the quality control system on the first page of inpatient medical records,and put forward improvement measures to improve the quality of the first page of inpatient medical records.Methods The quality control system of the first page of the inpatient medical records in a third-class hospital was improved.Then,obtain 1410 copies of quality control data on the first page of medical records from October 1 to December 31,2019 and 1410 copies of quality control data on the first page of medical records from October 1 to December 31,2020.The defect number and defect rate of the first page of the inpatient medical records were counted.By adopting χ~2,The quality control effect of the updated quality control system on the first page of inpatient medical records was evaluated.Results After improving the quality control system of the first page of inpatient medical records,The filling defect rates of basic information,diagnosis and treatment information and hospitalization information on the first page of medical records in surgical area decreased by 0.25%,0.16% and 0.29%,respectively,while those in internal medicine area decreased by 0.08%,0.23% and 0.09%;The defect rate of main operation and operation name,main operation and operation level,main operation and operation I assistant,main operation and operator,main operation and operation date decreased by 0.55%,0.20%,0.19%,0.18% and 0.15%,By adopting χ~2,P<0.05,with statistical significance.Conclusion After updating the quality control system of the front page of medical records,the quality of the front page of inpatient medical records has been improved,but there are still some problems.We need to continue to strengthen special quality control,clinician training and information construction,and implement the assessment of the first page of inpatient medical records,so as to further improve the quality of the first page of medical records.

关 键 词：住院病案首页 质控体系 缺陷率 

分 类 号：R197.323[医药卫生—卫生事业管理]