三级质控法在病历书写质量控制中的应用效果  

Application Effect of Three-Level Quality Control Method in Quality Control of Medical Record Writing

作　　者：葛苒 姜艳华 杨晓晖 GE Ran;JIANG Yanhua;YANG Xiaohui(Yangxin County Hospital of Traditional Chinese Medicine Medical Record Room,Binzhou 251800,Shandong,China)

机构地区：[1]阳信县中医医院病案室,山东滨州251800

出　　处：《中国卫生产业》2024年第7期66-69,共4页China Health Industry

摘　　要：目的探讨三级质控法在病历书写质量控制中的应用效果。方法选取阳信县中医医院病案室2022年1月—2023年12月病案室30名工作人员为研究对象,在2022年1—12月进行常规管理(对照组),2023年1—12月进行三级质控法管理(研究组),两组各随机抽取病案室的病历200份。对比两组病历书写的质量评分、不合格率、投诉率、医疗纠纷事件发生率。结果相较于对照组,研究组病历资料的书写质量评分均提高,差异有统计学意义(P均<0.05)。研究组病历书写不合格率低于对照组,差异有统计学意义(P均<0.05)。研究组因病历书写不合格导致的投诉率为1.50%(3/200)、医疗纠纷事件发生率为1.00%(2/200),低于对照组的7.00%(14/200)、6.50%(13/200),差异有统计学意义(χ^(2)=7.434、8.381,P均<0.05)。结论在医院病案室病历书写质量管理中,采用三级质控法进行加强质量控制,不仅能够有效提高病历书写质量,减少书写不合格情况,还能减少投诉、医疗纠纷事件。Objective To explore the application effect of three-level quality control method in the quality control of medical record writing.Methods From January 2022 to December 2023,30 staff members in the medical record room of Yangxin County Hospital of Traditional Chinese Medicine were selected as the research objects.Routine management was carried out from January to December 2022(control group),and three-level quality control management was carried out from January to December 2023(study group).200 medical records of the medical record room were randomly selected from each of the two groups.The quality score,unqualified rate,complaint rate and incidence of medical disputes were compared between the two groups.Results Compared with the control group,the writing quality scores of medical records in the study group were improved,and he difference were statistically significant(all P<0.05).The failure rate of medical record writing in the study group was lower than that in the control group,and the difference was statistically significant(all P<0.05).The complaint rate was 1.50%(3/200)and medical dispute incident rate was 1.00%(2/200)due to unqualified medical record writing in the study group were lower than 7.00%(14/200),6.50%(13/200)in the control group,and the differences were statistically significant(χ^(2)=7.434,8.381,both P<0.05).Conclusion In the quality management of medical record writing in the medical record room of the hospital,the three-level quality control method is used to strengthen the quality control,which can not only effectively improve the quality of medical record writing,reduce the unqualified writing,but also reduce complaints and medical disputes.

关 键 词：病案室 病历书写 质量管理 三级质控法 

分 类 号：R271[医药卫生—中医妇科学]