疑难病历缺陷的影响因素分析  

Analysis of Influencing Factors for Defects in Difficult Medical Records

作　　者：季海霞 鲍吉庆 JI Haixia;BAO Jiqing(Quality Management Department,Jiangsu People’s Hospital,The First Affiliated Hospital of Nanjing Medical University,Nanjing,Jiangsu,210000,China;Medical Record Office,Jiangsu People’s Hospital,The First Affiliated Hospital of Nanjing Medical University,Nanjing,Jiangsu,210000,China)

机构地区：[1]江苏省人民医院、南京医科大学第一附属医院质量管理处,江苏南京210000 [2]江苏省人民医院、南京医科大学第一附属医院病案科,江苏南京210000

出　　处：《江苏卫生事业管理》2023年第9期1228-1231,1236,共5页Jiangsu Health System Management

摘　　要：目的:回顾性分析某医院2019-2022年疑难病历,找出导致其缺陷的影响因素,为医院内部质量管理以及相关部门对医疗质量进行监管提供参考。方法:随机抽取某医院2019-2022年的疑难病历,参照病历评定标准对病历进行评定,评定结果分为缺陷组和无缺陷组。通过二元Logistic回归分析筛选导致疑难病历缺陷的影响因素。结果:共抽取1700份疑难病历,其平均住院天数20.51天,评定后缺陷组228份,无缺陷组1472份。将各病历临床特征作为研究变量。Logistic回归分析显示主要诊断为“肿瘤”“损伤中毒”、出院科室为“外科”“ICU”、治疗转归为“死亡”是导致疑难病历缺陷的危险因素(P<0.05)。是否危重则为保护因素。结论:疑难缺陷病历应作为病历质控的重点监管对象,医院和卫生部门应针对性地开展监督工作,进一步提升病历质量水平。Objective:To retrospectively analyze the difficult medical records of a certain hospital from 2019 to 2022,identify the influencing factors that lead to its defects,and provide reference for internal quality control management of the hospital and relevant departments’supervision of medical quality.Method:Randomly select difficult medical records from a certain hospital from 2019 to 2022,evaluate the medical records according to the medical record evaluation standards,and divide them into defect group and no defect group.Screening the influencing factors of difficult medical record defects through binary logistic regression analysis.Result:A total of 1,700 difficult medical records were selected,with an average hospital stay of 20.51 days.After evaluation,228 medical records were in the defect group and 1,472 medical records were in the none defect group.Using clinical features of each medical record as research variables.Logistic regression analysis showed that the main diagnosis was“tumor”,“injury poisoning”,the discharge department was“surgery”,“ICU”,and the treatment outcome was“death”,which were risk factors leading to difficult medical record defects(P<0.05).Whether the medical record is critical is a protective factor.Conclusion:Difficult and defective medical records should be a key regulatory object for medical record quality control,and hospitals and health departments should carry out targeted supervision work to further improve the quality level of medical records.

关 键 词：疑难病历 病历缺陷 影响因素 病历质控 

分 类 号：R197.39[医药卫生—卫生事业管理]