三级质控法结合专项质控管理模式对病历书写质量的影响  

The Impact of Three-Level Quality Control Method Combined With Specialized Quality Control Management Mode on the Quality of Medical Record Writing

作　　者：樊聪 FAN Cong(Department of Medical Record Statistics,the First People's Hospital of Tianmen in Hubei Province,Tianmen Hubei 431700,China)

机构地区：[1]湖北省天门市第一人民医院病案统计科,湖北天门431700

出　　处：《中国卫生标准管理》2023年第15期7-10,共4页China Health Standard Management

摘　　要：目的探讨临床病历书写质量控制中,三级质控+专项质控管理的实施价值。方法选取湖北省天门市第一人民医院2021年1月—2022年4月收治的200份病历,随机分为对照组和观察组,每组各100例。对照组给予专项质控管理,观察组在此基础上增加三级质控管理,两组均由同一批医师负责书写病历(共15名医师),比较不同质控管理模式的临床效果。结果观察组病历书写缺陷率低于对照组(P<0.05);观察组病历书写质量评分高于对照组(P<0.05);医师书写两组患者病历后,观察组自我工作能力评分高于对照组(P<0.05);观察组医师对管理工作的满意度明显高于对照组(P<0.05)。结论病历书写质量控制过程中,联合应用专项质控、三级质控法能够取得良好效果,在降低病历书写缺陷率的同时,提高了医师工作能力和病历书写质量,且医师对这一管理模式更为认可。Objective To explore the implementation value of three-level quality control and specialized quality control management in the quality control of clinical medical record writing.Methods A total of 200 medical records admitted to the First People's Hospital of Tianmen in Hubei Province from January 2021 to April 2022 were randomly divided into control group and observation group,with 100 cases in each group,The control group received special quality control management,while the observation group added three-level quality control management on this basis.Both groups were responsible for writing medical records by the same group of physicians(a total of 15 physicians),and the clinical effects of different quality control management models were compared.Results The defect rate of medical record writing in the observation group was lower than that in the control group(P<0.05).The score of medical record writing quality in the observation group was higher than that in the control group(P<0.05).After the doctors wrote the medical records of the two groups,the selfworking ability score of the observation group was higher than that of the control group(P<0.05).The satisfaction degree of the doctors in the observation group was significantly higher than that in the control group(P<0.05).Conclusion In the process of quality control for medical record writing,the combined application of specialized quality control and three-level quality control methods can achieve good results,reduce the defect rate of medical record writing,and improve the work ability and quality of doctors.Moreover,doctors are more recognized for this management model.

关 键 词：病历书写 三级质控法 专项质控管理 书写质量 医疗纠纷 书写缺陷 

分 类 号：R197[医药卫生—卫生事业管理]