医院肾病风湿科规范化病案管理提升病案质量的效果分析  

Effect Analysis of Standardized Medical Record Management in the De⁃partment of Nephrology and Rheumatology in Hospital to Improve theQuality of Medical Records

作　　者：徐敏 陈永美 徐红 XU Min;CHEN Yongmei;XU Hong(Department of Nephrology,Rheumatology and Immunology,Qingdao Jiaozhou Central Hospital,Qingdao,Shandong Province,266300 China)

机构地区：[1]青岛市胶州中心医院肾病风湿免疫科,山东青岛266300

出　　处：《中国卫生产业》2023年第12期16-19,共4页China Health Industry

摘　　要：目的分析在医院肾病风湿科病案管理中应用规范化病案管理模式的临床价值。方法选取2020年5月—2022年5月青岛市胶州中心医院肾病风湿免疫科30名医护人员和200份病案为研究对象,于2020年5月—2021年5月期间实施常规管理模式(对照组,30名医护人员与100份病案);2021年6月—2022年5月实施规范化病案管理模式(研究组,30名医护人员与100份病案)。比较两组不同管理模式下病案管理质量、病案管理缺陷发生率以及医护人员管理满意度。结果研究组应用规范化病案管理模式后,病案质量评分(入院记录、病程记录、出院记录、辅助检查及书写)明显高于对照组,差异有统计学意义(P<0.05)。研究组病案管理缺陷事件发生率较对照组更低,差异有统计学意义(P<0.05)。研究组满意度明显较对照组高,差异有统计学意义(P<0.05)。结论在医院病案管理中应用规范化病案管理模式,既可提升病案管理质量,也可降低病案质量缺陷发生率,规范医护人员病案管理流程,提高满意度,有管理实用价值。Objective To analyze the clinical value of applying standardized medical record management mode in the management of medical records in the department of nephrology and rheumatology in the hospital.Methods Thirty medical staff and 200 medical records from the Department of Nephropathy,Rheumatology and Immunology of Qing-dao Jiaozhou Central Hospital from May 2020 to May 2022 were selected as the study objects,and routine manage-ment mode was implemented from May 2020 to May 2021(control group,30 medical staff and 100 medical records);From June 2021 to May 2022,the standardized medical record management model will be implemented(study group,30 medical staff and 100 medical records).The quality of medical record management,the incidence of defects in medical record management and the satisfaction of medical staff were compared between the two groups under differ-ent management modes.Results After applying the standardized medical record management mode,the quality scores of medical records(admission records,course records,discharge records,auxiliary examination and writing)in the study group were significantly higher than those in the control group,and the difference was statistically significant(P<0.05).The incidence of disease record management defects in the study group was lower than that in the control group,and the difference was statistically significant(P<0.05).The satisfaction of the study group was significantly higher than that of the control group,and the difference was statistically significant(P<0.05).Conclusion The application of standardized medical record management mode in hospital medical record management can not only improve the qual-ity of medical record management,but also reduce the incidence of quality defects of medical record,standardize the medical record management process of medical staff,improve satisfaction,and have practical management value.

关 键 词：肾病风湿科 病案管理 管理质量 病案缺陷 评审 

分 类 号：R197[医药卫生—卫生事业管理]