基于病历四级质量监控体系的病历质量分析  

Quality Analysis of Medical Records Based on Four-Level Quality Monitoring System of Medical Records

作　　者：寇静恬 潘宇[1] 王亮[1] 李峒作 栾瑞[1] 梁超[1] 马原[1] 张松[1] 张温馨 唐文祥 Kou Jingtian;Pan Yu;Wang Liang(The First Affiliated Hospital of Harbin Medical University,Harbin,Heilongjiang,150001,China;不详)

机构地区：[1]哈尔滨医科大学附属第一医院,黑龙江哈尔滨150001

出　　处：《中国医院管理》2022年第8期64-66,共3页Chinese Hospital Management

摘　　要：目的 探讨病历四级质量监控体系在医院病历质量管理中的应用。方法 自2021年1月起应用病历四级质量监控体系,2020年为应用前,2021年为应用后,调取2020年、2021年抽检的运行病历存档材料,在应用前后各随机选取1 000份病历进行研究,比较应用前后病历质量情况。结果 应用后病历质量评分明显高于应用前(P<0.05),应用后三级查房制度、会诊制度、病历讨论制度、围手术期管理制度、知情同意制度缺陷、48 h内无主治医师首次查房记录、两次病程记录时间超过3 d、24 h内无转入记录、无术前小结和手术记录超过24 h的缺陷等占比明显低于应用前(P<0.05)。结论 应用病历四级质量监控体系进行医院病历质量管理,可显著提高病历书写质量,减少病历书写缺陷,有效提高病历书写的完整性和规范性,进一步加强病历的内涵质量。Objective To explore the application of the four-level quality monitoring system of medical records in the quality management of hospital medical records. Methods Since January 2021,the four-level quality monitoring system of medical records has been applied,the year before application is 2020,and the year after application is2021.The archiving materials of operational medical records sampled in 2020 and 2021 were collected,before and after application,1 000 medical records were randomly selected for research, and the quality of medical records before and after application was compared. Results The quality score of medical records after application was significantly higher than that before application(P<0.05),the proportion of defects in three-level ward round system,consultation system, medical record discussion system, perioperative management system, informed consent system,without first ward round record of attending physician within 48 hours,duration of two disease course records more than 3 days,without transfer records within 24 hours,without preoperative summary and operation records more than 24 hours after application was significantly lower than that before application(P<0.05). Conclusion The application of the four-level quality monitoring system of medical records in the quality management of medical records can significantly improve the quality of medical records writing,reduce the defects of medical records writing,effectively improve the integrity and standardization of medical record writing, and further strengthen the connotation of medical record quality.

关 键 词：病历 质控体系 质量管理 

分 类 号：R197.323.1[医药卫生—卫生事业管理]