双线双向督查机制在某三甲公立医院提升病案质量的应用效果分析  

Analysis of the Application Effect of Double Line and Double Direction Supervision Mechanism in Improving the Quality of Medical Records in a Three A and Tertiary Hospital

作　　者：高扬 沈健[1] 吴志强[1] 黄海军[1] 袁方 谷佳伟 张骏[1] Gao Yang;Shen Jian;Wu Zhiqiang;Hung Haijun;Yuan Fang;Gu Jiawei;Zhang Jun(Zhejiang Provincial People’s Hospital/People’s Hospital of Hangzhou Medical College,Hangzhou 310014,Zhejiang Province,China)

机构地区：[1]浙江省人民医院杭州医学院附属人民医院,浙江省杭州市310014

出　　处：《中国病案》2023年第12期10-13,共4页Chinese Medical Record

基　　金：浙江省人民医院优秀科研基金项目(ZRY2018C012)。

摘　　要：目的探索将双线双向督查机制运用到病案质量控制中,以期提高病历书写质量,为医院病案质控管理提供参考。方法梳理某院现有病案质控模式存在问题,建立双线双向督查机制,以2021年1月1日作为开始时间节点,收集整理2021年1月1日-2021年12月31日病案问题提交数11290条与医疗风险预警数31921条,进行逐月数据分析。覆盖全院35个临床科室,每科室10份,随机抽取2020年8月1日-2020年12月31日期间出院病案共350份病案作为改进前组;抽取2021年8月1日-2021年12月31日期间的350份出院病案作为改进后组进行比较。采用描述性统计方法描述问题病案数与医疗风险预警数变化,采用χ^(2)检验分析病案问题占比,评价改进后效果。结果2021年1月1日-2021年6月30日病案问题合计占全年问题的65.88%,医疗风险预警占全年的70.36%,高于2021年7月1日-2021年12月31日的34.12%和29.64%。改进前组住院病案首页有缺失病案占350份督查病案的27.43%,改进后占8.57%;入院记录不完整改进前组占40.57%,改进后组占9.71%;病程记录不完整改进前组占46.57%,改进后组占14.86%;手术记录不及时改进前组占29.71%,改进后组占8.86%;出院记录不完整改进前组占37.43%,改进后组占12.57%;辅助检查不及时改进前组占34.57%,改进后组占10.57%;医嘱下达不规范改进前组占41.43%,改进后组占11.14%,每项改进前组和改进后组缺陷率经χ^(2)检验,P值均<0.05,差异具有统计学意义。结论双线双向督查机制,线上着重病案的形式质控,线下着重病案内涵质控,全方位提升各级医师病案质控能力,以问题为抓手约谈医疗组长,有助于提高病历书写和病案管理质量。Objectives To improve the writing quality of medical records and explore the application of double-double supervision method to medical records quality control,so as to provide reference for medical records quality control in hospitals.Methods To sort out the problems in the existing medical record quality control mode of a hospital,establish a double-double supervision method,and take January 1st,2021 as the starting time node of the double-double supervision.From January 1st,2021 to December 31st,2021,11290 medical record problems and 31921 medical risk warnings were collected and analyzed month by month.It covered 35 clinical departments in the hospital,10 in each department.A total of 350 discharged medical records from August 1st,2020 to December 31st,2020 were randomly selected as the pre-improvement group;350 discharged medical records from August 1st,2021 to December 31st,2021 were selected as the improved group for comparison.Descriptive statistics were used to describe the changes in the number of problem cases and the number of medical risk early warning,andχ^(2) test was used to analyze the proportion of problem cases and evaluate the improved effect.Results From January 1st,2021 to June 30th,2021,the total number of medical record problems accounted for 65.88%of the annual problems,and medical risk warnings accounted for 70.36%of the annual problems,higher than the 34.12%and 29.64%of the annual problems from July 1st,2021 to December 31st,2021.Before the improvement,27.43%of the 350 cases were missing on the home page,and 8.57%were missing after the improvement.The incomplete admission records accounted for 40.57%before improvement and 9.71%after improvement;Incomplete course records accounted for 46.57%before improvement and 14.86%after improvement;29.71%before and 8.86%after the improvement of surgical records;Incomplete discharge records accounted for 37.43%before improvement and 12.57%after improvement;The pre-improvement group accounted for 34.57%,and the post-improvement group accounted for 10

关 键 词：双线双向督查 病案质量 质控体系 策略实践 

分 类 号：R197.323[医药卫生—卫生事业管理]