福建省某医院2016-2020年产科病历书写质量及影响因素分析  

Analysis on the Quality and Influencing Factors of Written Medical Records in Obstetrics in A Hospital in Fujian Province from 2016 to 2020

作　　者：谢安平 Xie Anping(Xiamen Fifth Hospital,Fujian Province,Xiamen,361101)

机构地区：[1]厦门市第五医院,福建省厦门市361101

出　　处：《中国病案》2022年第11期18-20,共3页Chinese Medical Record

摘　　要：目的分析福建省某院产科出院病案质量影响因素,为指导临床产科病案质量管理提供参考。方法采用多阶段分层群体随机抽样的方法抽取2016年1月1日-2020年12月31日每年500份产科病案,共计2500份,由病案统计科病案质控人员依据医院制定的《住院病案质量评分标准》对每一份病案质量进行评估。结果一级病案有2133份,占比92.44%。二级、三级、四级病案各占8.84%、4.92%和0.92%;共检查出缺项目905项,其中病案首页缺项、辅助检查缺失、病案书写格式不合格分别占35.47%、22.32%、20.11%;产科医师不同的年龄、学历、工作年限以及患者住院天数的病案质量合格率差异具有统计学意义(P<0.05)。二分类Logistic回归分析显示硕士及以上学历、年龄较大、工作时间较长是病案质量合格的因素,患者住院时间长是导致病案质量不合格的独立危险因素。结论病案质量缺陷主要表现为病案首页缺项、辅助检查缺失、病案书写格式不合格,病案书写医师年龄、工作年限、学历以及患者住院天数影响病案质量水平。Objectives This study aims to analyze the factors affecting the quality of discharge medical records in obstetrics department of a hospital in Fujian Province to provide reference for guiding the quality management of clinical obstetric medical records.Methods A multi-stage stratified population random sampling method was used to select 500 medical records every year from January 2016 to December 2020,with a total of 2500 cases.The quality of each medical record is evaluated by the medical record quality control personnel of the medical record statistics department according to the"Inpatient Medical Record Quality Scoring Standard"formulated by the hospital.Results There were 2133 Grade I qualified medical records,accounting for 92.44%.Grade II,III and IV medical records accounted for 8.84%,4.92%and 0.92%respectively.Among 2500 medical records,905 items were found missing,among which the missing items on the medical record front pages,the lack of auxiliary examinations,and the unqualified writing format of the medical records accounted for 35.47%,22.32%,and 20.11%,respectively.The medical record quality qualification rate of obstetricians with different ages,educational backgrounds,working years,and hospitalization days of patients was statistically significant(P<0.05).Binary Logistic regression analysis showed that master’s degree or above,older age,and longer working hours were the factors for qualified medical record quality.Length of hospital stay was an independent risk factor for unqualified medical records.Conclusions The quality defects of medical records were mainly manifested in the absence of items on the first page of the medical records,the lack of auxiliary inspections,and the unqualified writing format of the medical records.The medical record writing physician’s age,working years,education and the number of days in hospital all affected the quality of medical records.

关 键 词：产科 病案质量 影响因素 

分 类 号：R197.323[医药卫生—卫生事业管理]