中医病案管理与质量控制工作研究  

Research on medical records management and quality control of traditional Chinese medicine*

作　　者：睢桂茗 吴政谦 刘阳文 杨礼聪 高燕 罗涛 SUI Guiming;WU Zhengqian;LIU Yangwen;YANG Licong;GAO Yan;LUO Tao(Quality Control Office,Zhaotong Traditional Chinese Medicine Hospital,Zhaotong Yunnan 657000,China;Office of Dea,Zhaotong Traditional Chinese Medicine Hospital,Zhaotong Yunnan 657000,China;Medical Record Room,Zhaotong Traditional Chinese Medicine Hospital,Zhaotong Yunnan 657000,China)

机构地区：[1]昭通市中医医院质控办,云南昭通657000 [2]昭通市中医医院院长办公室,云南昭通657000 [3]昭通市中医医院病案室,云南昭通657000

出　　处：《云南医药》2024年第6期61-64,共4页Medicine and Pharmacy of Yunnan

基　　金：云南省中医药大学中医政策研究课题项目(2023ZC04)。

摘　　要：目的以医保支付改革为契机,强化培训;完善中医病案管理与质量控制体系,制定考评机制,以提高病案内涵及首页数据质量。方法本院2023年10月修订病案三级质量控制制度及质量控制考核制度前后,随机抽取2023年7月1日-2023年9月30日病案200份作为对照组,2024年1月1日-2024年3月31日病案200份作为实验组,将2组甲级病历率(%)进行统计学检验。结果2组甲级病历率差异有统计学意义(P<0.01),实验组甲级病历率达标。结论通过优化中医病案管理与质量控制体系及考评机制建设,可显著提高病案内涵及首页数据质量,促进医保资金合理使用。Objective Take the reform of medical insurance payment as an opportunity to strengthen training,improve the medical records management and quality control system of traditional Chinese medicine(TCM),and formulate the evaluation mechanism,in order to improve the connotation of medical records and the quality of first page data.Methods Before and after the revision of the three-level quality control system and quality control assessment system of medical records in our hospital in October 2023,200 medical records from July 1,2023 to September 30,2023 were randomly selected as the control group,and another 200 medical records from January 1,2024 to March 31,2024 were randomly selected as the experimental group.Statistically tested the rate(%)of grade A medical records in the two groups.Results There was statistical significance between the two groups(P<0.01),and the experimental group reached the standard.Conclusions By optimizing the management and quality control system of TCM medical records and the construction of evaluation mechanism,the connotation of medical records and the quality of data on the first page data can be significantly improved,and the rational use of health insurance funds can be promoted.

关 键 词：中医病案 病案管理 病案质量控制 

分 类 号：R197.3[医药卫生—卫生事业管理]