北京市31家医院乳腺癌化疗住院病历质控结果分析  

Analysis of Quality Control Results of Medical Records among Inpatients with Breast Cancer Chemotherapy in 31 Hospitals in Beijing

作　　者：安宇 邓明 杨娟 林伟龙 杨谨成 杨文静 AN Yu;DENG Ming;YANG Juan(National Cancer Center/National Cancer Clinical Research Center/Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing,100021,China;不详)

机构地区：[1]国家癌症中心/国家肿瘤临床医学研究中心/中国医学科学院北京协和医学院肿瘤医院,北京100021 [2]国家癌症中心/国家肿瘤临床医学研究中心/中国医学科学院北京协和医学院肿瘤医院癌症诊治质控办公室,北京100021

出　　处：《中国卫生质量管理》2022年第11期16-20,共5页Chinese Health Quality Management

基　　金：国家重点研发计划项目——肿瘤智能诊疗支持系统开发、验证及推广(编号:2021YFF1201305)。

摘　　要：目的了解北京市31家医院2020年乳腺癌化疗住院病历质控现状,并提出改进建议。方法以2020年北京市化疗质控检查中31家医院的106份乳腺癌化疗住院病历为研究对象,应用SPSS 22.0软件进行数据统计,采用一般描述性分析、两独立样本t检验、配对样本t检验等方法进行数据分析。结果化疗过程质控亟待改善项目包括药物选择、剂量、用法记录以及化疗知情同意、化疗前常规检查、肿瘤分期,药事质控亟待改善项目为化疗方案确定及药物应用剂量是否有依据说明、药物输注时间是否合理。二三级医院比较,化疗病历质控评分总分、化疗过程质控评分、药事质控评分均不具有统计学意义(P>0.05);肿瘤内科化疗病历质控评分总分、化疗过程质控评分与非肿瘤科比较,差异均具有统计学意义(P<0.05)。结论北京市医院乳腺癌规范化诊疗水平还存在较大改进空间。后续需以乳腺癌单病种质控工作为基础,制定乳腺癌单病种质控指标,规范病历书写,提高非肿瘤科医师乳腺癌化疗能力。Objective To investigate the status of medical record quality control of breast cancer inpatients undergoing chemotherapy in 31 hospitals in Beijing in 2020,and to put forward suggestions for improvement.Methods A total of 106 breast cancer chemotherapy inpatients from 31 hospitals in Beijing in 2020 were selected as the research object.SPSS 22.0 software was used for data statistics.General descriptive analysis,two independent sample t-test,paired sample t-test and other methods were used for data analysis.Results The urgent improvement items in the process of chemotherapy included the records of drug selection,dosage,usage,informed consent for chemotherapy,routine detection before chemotherapy,tumor staging.The urgent improvement items in the quality control of drug were the determination of chemotherapy regimen,whether the dosage of drug was justified,and whether the time of drug infusion was reasonable.Compared with secondary and tertiary hospitals,the total score of quality control score of chemotherapy medical records,quality control score of chemotherapy process,and quality control score of pharmaceutical affairs were not statistically significant(P>0.05).There were significant differences in the total score of quality control score of medical records of chemotherapy and the quality control score of chemotherapy process between medical oncology department and non-oncology department(P<0.05).Conclusion There is still room for improvement in the standard diagnosis and treatment of breast cancer in medical institutions in Beijing.Based on the quality control work of single breast cancer disease,quality control indicators of single breast cancer disease should be formulated,medical records should be standardized,and chemotherapy ability of non-oncologists should be improved.

关 键 词：乳腺癌 化疗 住院病历 单病种质量管理 

分 类 号：R737.9[医药卫生—肿瘤] R197.323[医药卫生—临床医学]