思维导图在病案首页和护理质控中的探索与应用  

Exploration and application of mind mapping in medical record homepage and nursing quality control

作　　者：王玉红 杨优帅 靳苗 宋艳龙 WANG Yuhong;YANG Youshuai;JIN Miao;SONG Yanlong(Shanxi Provincial Medical Service Evaluation Center,Shanxi Province,Taiyuan030000,China;Talent Center,Health Commission of Shanxi Province,Shanxi Province,Taiyuan030000,China;Department of Analysis,Linfen People’s Hospital,Shanxi Province,Linfen041000,China)

机构地区：[1]山西省医疗服务评价中心,山西太原030000 [2]山西省卫生健康委员会人才中心,山西太原030000 [3]山西省临汾市人民医院统计室,山西临汾041000

出　　处：《中国医药导报》2024年第30期171-174,共4页China Medical Herald

摘　　要：目的探索思维导图在病案首页和护理质控中的应用及效果。方法本研究采用随机抽样原则抽取山西省临汾市人民医院2021年1月至12月未应用思维导图的43107份出院病历中50份和2022年1月至12月应用思维导图的48369份出院病历中50份比较病案首页项目及护理项目填写的完整率和正确率,评价对山西省临汾市人民医院全体医务人员进行培训后,并将思维导图运用于病案首页及护理项目质量控制的效果。结果应用思维导图后,2022年病案首页填写完整率高于2021年(P<0.05),应用思维导图后,基本信息、入院病情、主要诊断选择、主要手术选择病案首页项目正确率均较应用前提高(P<0.05)。应用思维导图后,2022年护理项目的填写完整率和正确率也均高于2021年(P<0.05)。结论思维导图可以帮助医务人员理清头绪,思考病案首页和病历中各项信息的逻辑关系,有效提升病案首页及护理项目书写的完整率和正确率。将思维导图运用于病历质控当中,有利于提高病案首页质量。Objective To explore the application and effect of mind mapping in medical record homepage and nursing quality control.Methods In this study,A total of 50 out of 43107 medical records discharged from Linfen People’s Hospital of Shanxi Province from January to December,2021,who did not apply mind mapping,and 50 of 48369 medical records discharged from January to December,2022 by using mind mapping were selected by random sampling principle,and the completeness and accuracy of filling in the first page items of medical records and nursing items were compared.After training all the medical staff in Linfen People’s Hospital of Shanxi Province,the effect of applying mind map to the first page of medical records and the quality control of nursing items was evaluated.Results After the application of mind mapping,the completion rate of the first page of medical records in 2022 was higher than that in 2021(P<0.05).After the application of mind mapping,the accuracy rate of basic information,admission condition,major diagnosis selection,and major surgical selection of medical records first page items was improved compared with that before the application(P<0.05).After applying mind mapping,the completion rate and accuracy rate of nursing projects in 2022 were also higher than those in 2021(P<0.05).Conclusion Mind mapping can help medical staff to clear their heads,think about the logical relationship between the first page of medical records and the information in the medical records,and effectively improve the completeness and accuracy of the writing of the first page of medical records and nursing items.The application of mind map in medical record quality control is beneficial to improve the quality of the first page of medical records.

关 键 词：思维导图 病案首页 质控 

分 类 号：R197.3[医药卫生—卫生事业管理]