2021-2022年5所军队医院门诊病历质量调查分析  

Investigation of the quality of outpatient medical records in 5 military hospitals from 2021 to 2022

作　　者：温红霞 万辉 董巧儿 Wen Hongxia;Wan Hui;Dong Qiaoer(Medical Management Office,The Teaching and Research Support Center,Naval Medical University,Shanghai 200433,China)

机构地区：[1]海军军医大学教研保障中心医疗管理室,上海200433

出　　处：《海军医学杂志》2024年第6期591-595,共5页Journal of Navy Medicine

摘　　要：目的 分析2021-2022年5所军队医院门诊病历质量情况,旨在提高门诊病历书写质量。方法 抽查2021-2022年5所军队医院358份门诊病历,依据本单位门诊病历督查标准进行评价,该标准的α信度系数为0.417,KMO值为0.6,Bartlett球形检验P<0.05。结果 2021-2022年5所军队医院358份门诊病历合格率为81.56%,专科门诊病历合格率(94.12%)高于外科和内科(84.35%、74.86%),差异有统计学意义(P<0.05)。病历缺陷项目主要涉及既往史、现病史、处置和辅助检查。二级医院门诊病历的既往史、医师签名缺陷率(33.56%、8.90%)高于三级医院(19.81%、3.77%),三级医院门诊病历的辅助检查、查体缺陷率(16.51%、14.62%)高于二级医院(8.22%、6.16%),差异有统计学意义(P<0.05)。外科门诊病历的既往史、一般项目缺陷率(37.39%、16.52%)高于其他科别,专科门诊病历的现病史、主诉、辅助检查缺陷率(36.76%、23.53%、25.00%)高于其他科别,内科门诊病历的查体、诊断缺陷率(14.86%、12.00%)高于其他科别,差异均有统计学意义(P<0.05)。结论 2021-2022年5所军队医院门诊病历质量整体良好,但存在一些书写缺陷,各级医院、各科别应加强门诊病历书写培训与质量控制,持续深化门诊病历质量管理。Objective To explore the quality of outpatient medical records of 5 military hospitals from 2021 to 2022,so as to improve the writing quality of outpatient medical records.Methods A total of 358 outpatient medical records of 5 military hospitals from 2021 to 2022 were sampled and evaluated based on the supervision standards of outpatient medical records of the corresponding hospitals.The reliability coefficient of the standard was 0.417,KMO value was 0.6,and the significance of Bartlett’s sphericity test was less than 0.05.Results The qualified rate of 358 outpatient records of 5 military hospitals from 2021 to 2022 was 81.56%.The qualified rate of outpatient records was 94.12%in the departments of medical specialties,which was significantly higher than that of the departments of surgery and internal medicine(84.35%,74.86%,P<0.05).The defect items of medical records were mainly past history,current medical history,treatment and auxiliary examination.The defect rates of past history and physician signature in outpatient medical records of levelⅡhospitals were 33.56%and 8.90%,respectively,which were significantly higher than those of levelⅢhospitals(19.81%,3.77%,P<0.05).The defect rates of auxiliary examination and physical examination in outpatient medical records of levelⅢhospitals were16.51%and 14.62%,respectively,which were significantly higher than those of levelⅡhospitals(8.22%,6.16%,P<0.05).The defect rates of past history and general items in outpatient records of the department of surgery were 37.39%and 16.52%,respectively,which were significantly higher than those of other departments(P<0.05).The defect rates of current medical history,chief complaint and auxiliary examination in outpatient records of the departments of medical specialties were 36.76%,23.53%,and 25.00%,respectively,which were significantly higher than those of other departments(P<0.05).The defect rates of physical examination and diagnosis in outpatient records of the department of internal medicine were 14.86%and 12.00%,which w

关 键 词：军队医院 门诊病历 质量分析 

分 类 号：R197[医药卫生—卫生事业管理]