病案首页质量的影响因素及质控管理方案的应用  

The influencing factors of the quality of medical record homepage and the application of quality control management plan

作　　者：魏燕玲 WEI Yanling(Yumen First People’s Hospital,Yumen 735211,China)

机构地区：[1]玉门市第一人民医院,甘肃玉门735211

出　　处：《现代医院》2025年第3期385-387,392,共4页Modern Hospitals

摘　　要：目的分析病案首页质控的影响因素及质控管理方案的应用效果。方法对某院2023年12月出院病案中的1000份病案首页进行质控,质控后的结果作为对照组(传统管理)的基础数据,然后根据质控出的问题找出影响因素,提出质控管理方案,与医师及病案科质控员进行沟通及对改进方案进行宣贯,意见达成一致后进行方案的实施,在实施的过程中随时根据新出现的问题调整改进方案,通过半年的质控管理方案的应用后,对2024年8月出院病案中的1000份病案首页进行质控,质控后的结果作为观察组(全面质控管理方案)。对比效果。结果管理前,对照组不合格率为22.30%,管理后,观察组不合格率为10.10%,对照组不合格率显著高于观察组,差异具有统计学意义(P<0.05)。观察组主要诊断填写正确率、主要手术编码正确率高于对照组,差异具有统计学意义(P<0.05)。结论采取全面质控管理方案能够有效降低病案首页填写问题发生率,效果显著。Objective To analyze the influencing factors of quality control on the first page of medical records and the application of quality control management plans.Methods Quality control was conducted on the first page of 1000 medical records discharged from our hospital in December 2023.The results of the quality control were used as the basic data for the control group(traditional management).Based on the problems identified during the quality control,influencing factors were identified,and a quality control management plan was proposed.After communication with physicians and medical record department quality control personnel and promotion of the improvement plan,the plan was implemented.During the implementation process,the improvement plan was adjusted according to new problems at any time.After applying the quality control management plan for six months,the first page of 1000 medical records discharged in August 2024 were quality controlled,and the results of the quality control were used as the observation group(comprehensive quality control management plan).Comparison effect.Results Before management,the unqualified rate of the control group was 22.30%.After management,the unqualified rate of the observation group was 10.10%.The unqualified rate of the control group was significantly higher than that of the observation group,and the difference was statistically significant(P<0.05).The observation group had a higher accuracy rate in filling in the main diagnosis and the main surgical code than the control group,and the difference was statistically significant(P<0.05).Conclusion The comprehensive control and management scheme can effectively reduce the incidence of problems on the home page of medical records,with remarkable results.

关 键 词：质控管理方案 病案首页质量 临床效果 

分 类 号：R197.323.1[医药卫生—卫生事业管理]