5所军队医院病历质量管理现况分析  

Analysis on the status quo of medical record quality management in five military hospitals

作　　者：林雪茹 郑楷炼 余泰 董巧儿 Lin Xueru;Zheng Kailian;Yu Tai;Dong Qiaoer(Teaching and Research Support Center,Naval Medical University,Shanghai 200433,China)

机构地区：[1]海军军医大学教研保障中心,上海200433 [2]海军军医大学第一附属医院肝胆胰外科

出　　处：《海军医学杂志》2023年第2期109-115,共7页Journal of Navy Medicine

摘　　要：目的深入了解军队医院病历质量管理现况,区分军队医院病历质量管理的优劣,为军队医院提高病历管理质量、顺应时代发展提供思路和方法。方法根据某市病历质量控制标准,选取2020年5所军队医院的历史病历,为其打分测评,得出缺陷项目具体数值,并进行统计分析。结果军队医院在门急诊病历、住院病历、病案管理方面都存在一定问题。需要根据相关政策与评价标准,对薄弱环节和重点质控项目加以改进。结论军队医院需要在病历建设方面继续予以重视并加大投入,从病历质量这一基础要素入手,以点带面提升医院管理水平,提高自身保障能力。Objective To gain an in‐depth understanding of the quality management of medical records in military hospitals in recent years,and to distinguish the advantages and disadvantages of medical records quality management in military hospitals,so as to provide ideas and methods for the development of the time.Methods According to the quality control standards of medical records in a certain city,the past medical records of the five military hospitals in 2020 were selected for scoring and evaluation,specific values of defective items were obtained for statistical analysis.Results There existed certain problems concerning outpatient emergency medical records,inpatient medical records,and medical record management in the military hospitals,and it was necessary to improve weak links and key quality control projects in accordance with relevant policies and evaluation standards.Conclusion It is mandatory for military hospitals to improve hospital management level and enhance self‐support capability from basic element to medical records quality by using the method of fanning out from point to area.

关 键 词：军队医院病历质量 现状调查 电子病历 人才培养模式 

分 类 号：R197[医药卫生—卫生事业管理]