湖南省某三甲医院5667份出院病案质量分析  

Analysis of the quality of 5667 medical records in a tertiary hospital in Hunan province

作　　者：陈香兰 奉水东[2] 刘波[1] 李芳[1] 陈慧 周王艳 Chen Xianglan;Feng Shuidong;Liu Bo;Li Fang;Chen Hui;Zhou Wangyan(The First Affiliated Of University Of South China,Hunan Province,Hengyang,421001;不详)

机构地区：[1]南华大学附属第一医院,湖南省衡阳市421001 [2]南华大学公共卫生学院,湖南省衡阳市421001

出　　处：《中国病案》2023年第12期34-37,共4页Chinese Medical Record

摘　　要：目的通过评价出院病历书写质量,以期提高医院病历书写质量,助力DRGs付费和三级公立医院绩效考核。方法通过分层随机抽样的方法抽取湖南省某三甲医院所有住院医师2021年1月1日-2021年12月31日期间每月2份出院病案,共计抽取5667份。参照《住院病历质量评分标准(2019年试行稿)》进行质控,描述病历书写缺陷,通过卡方检验、Logistic回归分析导致病案缺陷的相关因素。结果5667份终末病案中合格率为96.61%。不合格病案缺陷分布按构成比排前3位的依次是:日常病程记录记录缺陷占64.58%;出院或死亡记录缺陷占52.60%;入院记录中主诉、现病史、既往史描述错误占48.44%。单因素分析显示:病案不合格率在医师性别和患者住院天数、是否转科、离院方式等因素的不同组别之间对病案不合格率影响差异有统计学意义,P<0.05;医师职称、病案分型、科室分布、有无手术/介入比较,差异无统计学意义,P>0.05。Logistic回归分析显示:男性医师病历书写质量不合格率高于女医师,OR=1.910,P<0.05;住院天数≥10天的出院患者病案不合格率高于住院天数<10天者,OR=1.825,P<0.05;转科患者病案不合格率高于非转科患者,OR=38.207,P<0.05;非医嘱离院病案不合格率高于医嘱离院者,OR=1.599,P<0.05。结论日常病程记录、出院记录、入院记录是影响病案质量的主要因素,并且应加强对男性医师、住院天数长、转科以及非医嘱离院病案的关注。Objectives To improve the writing quality of hospital medical records,facilitate the payment by diagnosis related groups(DRGs)and performance appraisal of tertiary public hospitals.Methods Two medical records per month of all residents in a ClassⅲGrade A hospital in Hunan Province in 2021 were selected by stratified random sampling.The defects in medical records writing were described according to the Quality Score Criteria for medical records in Hospitals(2019 draft).The related factors leading to medical records defects were analyzed by chi-square test and logistic regression.Results A total of 5667 final medical records were randomly examined,and the qualified rate was 96.61%.According to the constituent ratio,the top three defects in the distribution of unqualified medical records were:defects in daily medical history records(64.58%),defects in discharge or death records(52.60%),and errors in the description of chief complaint,present medical history and past history in admission records(48.44%).Univariate analysis showed that there were statistically significant differences in the disqualification rate of medical records among different groups of factors such as physician's gender,length of stay,whether to transfer department,way of discharge(P<0.05).There were no significant differences in physician titles,medical records,department distribution,surgery/intervention(P>0.05).Logistic regression analysis showed that:The unqualified rate of medical records written by male doctors was higher than that of female doctors(OR=1.910,P<0.05),and the unqualified rate of medical records of discharged patients with hospitalization days≥10 days was higher than that of patients with hospitalization days less than 10 days(OR=1.825,P<0.05).The unqualified rate of medical records of patients in transfer department was higher than that of patients without transfer department(OR=38.207,P<0.05),and the unqualified rate of medical records of patients leaving hospital without medical advice was higher than that of patients le

关 键 词：终末病案 病案缺陷 因素分析 回归分析 

分 类 号：R197.323[医药卫生—卫生事业管理]