基于三级医院绩效考核标准耳鼻咽喉科病案管理新模式的构建及实践分析  

Construction and practice analysis of a new model of medical record management in otorhinolaryngology department based on the performance appraisal standard of tertiary hospitals

作　　者：邱秋群 张立娣 QIU Qiuqun;ZHANG Lidi(Medical record management department,Fuyong People's Hospital,Bao'an District,Shenzhen Guangdong 518103,China;Hemodialysis room,Fuyong People's Hospital,Bao'an District,Shenzhen,Guangdong 518103,China)

机构地区：[1]深圳市宝安区福永人民医院病案管理科,广东深圳518103 [2]深圳市宝安区福永人民医院血透室,广东深圳518103

出　　处：《医药前沿》2023年第32期21-23,共3页Journal of Frontiers of Medicine

摘　　要：目的:基于三级医院绩效考核标准建立耳鼻咽喉科病案管理新模式,分析应用实践效果。方法:选取深圳市宝安区福永人民医院2021年6月—2022年5月病案管理模式改进前220例耳鼻咽喉科患者住院病案(设为改进前组),以及2022年8月—2023年5月病案管理模式改进后220例耳鼻咽喉科患者住院病案(设为改进后组)为观察对象,比较病案管理模式改进前后病案首页填写总体合格率及重点质量控制项目填写合格率,分析病案首页填写问题分布情况。结果:改进后组耳鼻咽喉科病案首页填写总体合格率为98.18%,高于改进前组的94.55%(P<0.05);改进后组耳鼻咽喉科病案首页中的主要诊断填写合格率为98.18%、其他诊断填写合格率为99.55%、手术操作填写合格率为99.09%,高于改进前组的主要诊断填写合格率90.91%、其他诊断填写合格率89.09%、手术操作填写合格率91.36%(P均<0.05)。改进后组耳鼻咽喉科病案管理模式病案首页填写存在的问题,主要诊断的选择错误及不规范情况、其他诊断的填写不全及不规范情况、手术操作不规范情况均明显少于改进前组(P均<0.05)。结论:基于三级医院绩效考核标准建立耳鼻咽喉科病案管理新模式,能够明显减少病案首页缺陷及问题,提升病案首页质量。Objective Based on the performance appraisal standards of tertiary hospitals,a new model of medical record management in otorhinolaryngology department was established,and the application effect was analyzed.Methods The medical records of 220 patients with otorhinolaryngology before the improvement of medical record management mode from June 2021 to May 2022 in Fuyong People's Hospital were selected as the pre-improvement group,and the medical records of 220 patients with otorhinolaryngology after the improvement of medical record management mode from August 2022 to May 2023 were selected as the post-improvement group.The overall qualified rate of filling in the first page of medical records before and after the improvement of medical record management mode and the qualified rate of filling in key quality control items were compared,and the distribution of filling problems in the first page of medical records was analyzed.Results The overall qualified rate of the front page of the otorhinolaryngology medical records in the improved group was 98.18%,which was significantly higher than that in the pre-improved group(94.55%)(P<0.05).The qualified rate of main diagnosis filling in the first page of otorhinolaryngology medical records in the improved group was 98.18%,the qualified rate of other diagnosis filling was 99.55%,and the qualified rate of surgical operation filling was 99.09%,which was significantly higher than that in the improved group.The qualified rate of main diagnosis filling was 90.91%,the qualified rate of other diagnosis filling was 89.09%,and the qualified rate of surgical operation filling was 91.36%(P<0.05).Before and after the improvement of the medical record management mode of otorhinolaryngology in the improved group,the selection errors and irregularities of the main diagnoses in the filling of the first page of the medical record,the incomplete and irregular filling of other diagnoses,and the irregular operation of the operation were significantly less than those in the improved group(P<0.0

关 键 词：三级医院 绩效考核标准 病案首页 病案管理 质量控制 

分 类 号：R764[医药卫生—耳鼻咽喉科]