重点项目清单在儿童医院运行病历质量管理中的作用  

The role of the key items list in the quality control of running medical records of a children's hospital

作　　者：程潇 冀晨 赵旻鹏 东振彩[1] 李丽静[1,2] CHENG Xiao;JI Chen;ZHAO Minpeng;DONG Zhencai;LI Lijing(Tianjin Children's Hospital,Tianjin University Children's Hospital,Tianjin 300134,China;Tianjin Quality Control Center of Medical Records,Tianjin 300190,China)

机构地区：[1]天津市儿童医院//天津大学儿童医院,天津300134 [2]天津市病案质量控制中心,天津300190

出　　处：《现代医院》2024年第3期371-373,共3页Modern Hospitals

基　　金：天津市医院协会医院管理研究项目(2022zc07)。

摘　　要：目的通过比较运行病历质控指标的变化情况,分析病历质量管理重点项目清单在运行病历质控工作中的作用,探索科学有效的病历质量管理方式。方法基于目标设置理论,围绕目标激励效用的影响因素制定病历质量管理重点项目清单,自2023年4月起在天津市某三甲儿童医院正式实施。收集该医院2022年6月—2023年9月抽查的4823份运行病历,运用统计学方法比较重点项目清单实施前后各类质控项目的缺陷率。结果重点项目清单实施后,运行病历质控平均得分有所提高,总缺陷率由13.63%下降至7.94%,入院记录与首程记录、上级医师查房记录、会诊记录、手术记录缺陷率分别由4.25%、3.07%、8.26%、10.56%下降至1.61%、1.56%、4.41%、5.06%。结论实施重点项目清单管理能够有效提高运行病历书写质量,减少病历书写缺陷,实现病历管理水平提升。Objective To analyze the role of the key items list in the quality control of running medical records by comparing the improvements of the quality of medical records,and to explore more effective ways of quality management of medical records.Methods Based on the goal setting theory and influencing factors of goal incentive utility,a list of key items for medical record quality management was formulated,which was implemented in a children's hospital in Tianjin since April 2023.A total of 4823 operating medical records were collected from June 2022 to September 2023,and the defect rates of quality control items were compared by using statistical methods.Results After the implementation of the key items list,the average score of operating medical records was improved,and the defect rate decreased from 13.63%to 7.94%.Moreover,the defect rates of admission records,first-trip records,senior physician rounds records,consultation records,and surgical records decreased from 4.25%,3.07%,8.26%,and 10.56%to 1.61%,1.56%,4.41%,and 5.06%.Conclusion The implementation of key items list management can effectively improve the quality of running medical records,reduce the defects of medical records,and improve the effects of medical record management.

关 键 词：运行病历 质量管理 改进效果 目标设置理论 

分 类 号：R197.323.1[医药卫生—卫生事业管理]