基于运行病历管理的前置环节控制在病历质控中的作用分析  

Analysis of the Role in the Quality Control of Medical Records Based on the Advance Management of the Running Medical Records

作　　者：徐艳波 李佳 刘颖[1] XU Yanbo;LI Jia;LIU Ying(Medical Department of Chifeng hospital,Chifeng,Inner Mongolia Autonomous Region,024000 China)

机构地区：[1]赤峰市医院医务部,内蒙古赤峰024000

出　　处：《中国卫生产业》2022年第13期40-42,54,共4页China Health Industry

摘　　要：目的分析医院某一年全院运行病历质量管理数据,探索前置环节质量控制在全流程病历质控工作中的作用,提高病案质量,保障医疗安全。方法采集某三甲医院2021年1—12月抽查过的15300份运行病历质控信息,通过统计学方法分析运行病历存在的问题构成,总结出前置质控对提高病历书写质量带来的优势。结果2021年各季度病历二轮质控时问题病历均进行改进,改进率波动于30.77%~84.94%,整年数据总体呈现上升趋势。2021年运行病历环节质量考核具体问题构成中入院记录存在问题占比0.43%,病程记录(病历内涵)中存在问题占比最高,占76.18%,医患沟通记录、知情文件存在问题占比23.4%。结论运行病历管理,环节质量控制能够干预医师书写病历行为,提前质控病历,及时发现病历存在的问题,督促整改。Objective To analyze the quality management data of the running medical records of the hospital in a certain year,and explore the role of advance quality control in the whole process of medical record quality control.Methods The information of 15300 running medical records quality control from January to December 2021 was collected,and composition of problems in running medical records were analyzed by statistical methods.The advantages of advance quality control for improving the quality of medical record writing are summarized.Results During the second round of quality control of medical records in each quarter in 2021,the problematic medical records will be improved,and the improvement rate will fluctuate from 30.77%to 84.94%,and the data throughout the year generally shows an upward trend.Among the specific problems in the quality assessment of the medical record link in 2021,the proportion of problems in admission records accounted for 0.43%,the proportion of problems in the course records(connotation of medical records)was the highest,accounting for 76.18%,and the problems in doctor-patient communication records and informed documents accounted for 23.4%.Conclusion Running medical record management and link quality control can interfere with doctors'behavior of writing medical records,control medical records in advance,timely find problems in medical records and urge departments to rectify.

关 键 词：运行病历 病历书写质量 病历管理 质量控制 

分 类 号：R19[医药卫生—卫生事业管理]