某三甲医院终末病历内涵质量改进效果分析  

Analysis of the effect of improving the content quality of terminal medical records in a tertiary hospital

作　　者：季爽华 李全欢[1] 郑海娣[1] JI Shuanghua;LI Quanhuan;ZHENG Haidi(The First Affiliated Hospital of Zhejiang University School of Medicine,Hangzhou 310000,China)

机构地区：[1]浙江大学医学院附属第一医院,浙江杭州310000

出　　处：《现代医院》2024年第7期1058-1061,共4页Modern Hospitals

摘　　要：目的分析某三甲医院终末病历内涵质量检查结果,总结常见问题的原因并提出整改措施,为进一步高效实施病历质量管理工作提供依据。方法按照浙江省病历质量评分标准,制定医院出院病历质量检查评分表,随机抽取医院在2023年1月1日—2023年12月31日期间出院的7140份终末病历进行内涵质量检查,并比较质量整改前后的出院病历合格率及主要缺陷发生率。结果整改措施实施后出院病历总合格率由84.76%提高至91.38%,单项否决病历率由6.07%降至2.32%,差异有统计学意义(P<0.05)。整改后出院病历中主要缺陷问题及主要单项否决问题出现的频次均有下降,两组比较差异均有统计学意义(P<0.05)。缺72小时谈话记录、缺术后首程的问题频率在整改前后无明显变化,差异无统计学意义(P>0.05)。整改后十二分制扣分≥6分的医疗组由28个减少为8个,差异有统计学意义(P<0.05)。结论很多因素可影响病历书写质量。通过实施一系列整改措施,例如加强病历书写培训、加强病案管理四级质量监控体系、完善奖惩制度、构建方便快捷的交流平台、加强环节质量管理等方法,可有效提高病案书写质量。Objective To analyze the results of the quality inspection of the content of terminal medical records in a tertiary hospital,summarize the causes of common problems,and propose corrective measures to provide a basis for the efficient implementation of medical record quality management work.Methods Based on Zhejiang Province medical record quality scoring criteria,a medical record quality inspection scoring form was developed for the hospital.A total of 7,140 terminal medical records discharged from the hospital between January 1,2023,and December 31,2023,were randomly selected for content quality inspection.The discharge rate and major defect occurrence rate of medical records before and after quality improvement were compared.Results After the implementation of corrective measures,the overall qualification rate of discharged medical records increased from 84.76%to 91.38%,and the rate of individual vetoed medical records decreased from 6.07%to 2.32%,with statistically significant differences(P<0.05).The frequency of major defect issues and major individual veto issues in discharged medical records decreased after the improvement,with statistically significant differences in the two groups(P<0.05).The frequencies of issues regarding the lack of a 72-hour conversation record and the lack of the first postoperative course did not show significant changes before and after the improvement,with no statistically significant differences(P>0.05).After the improvement,the number of medical teams with a twelve-point deduction score≥6 decreased from 28 to 8,with statistically significant differences(P<0.05).Conclusion Many factors can affect the quality of medical record writing.By implementing a series of corrective measures such as strengthening medical record writing training,enhancing the four-level quality monitoring system of medical record management,improving the reward and punishment system,establishing a convenient and efficient communication platform,and strengthening quality management in various stages,the qua

关 键 词：终末病历 内涵质量 改进 分析 

分 类 号：R197[医药卫生—卫生事业管理]