根本原因分析法在病历书写规范及医疗质量管理中的应用效果分析  

Analysis of the Application Effect of Root Cause Analysis Method in Medical Record Writing Standard and Medical Quality Management

作　　者：朱圆圆 顾惠兴 王小位 ZHU Yuanyuan;GU Huixing;WANG Xiaowei(Medical Education,Suzhou Industrial Park Xingpu Hospital,Suzhou 215216,Jiangsu,China)

机构地区：[1]苏州工业园区星浦医院医教科,江苏苏州215216

出　　处：《中国卫生产业》2024年第23期82-85,共4页China Health Industry

摘　　要：目的分析根本原因分析法在病历书写规范及医疗质量管理中应用的效果。方法选取2022年1月—2023年12月苏州工业园区星浦医院的92名医务人员为研究对象,按照管理模式不同分组,常规组于2022年1—12月行常规管理,研究组于2023年1—12月行根本原因分析法管理。此外,两阶段分别抽取200份病历,统计病历书写情况。比较两组病历书写合格情况、病历书写缺陷发生情况、病历书写规范及医疗质量管理评分以及医务人员对管理模式的满意情况。结果研究组病历书写的合格率为98.00%(196/200),高于常规组的90.50%(181/200),差异有统计学意义(χ^(2)=10.379,P<0.05)。研究组病历书写缺陷发生率低于常规组,差异有统计学意义(P<0.05)。研究组病历书写规范及医疗质量管理评分比常规组高,差异有统计学意义(P均<0.05)。研究组对管理模式满意度评分比常规组高,差异有统计学意义(P均<0.05)。结论在病历书写规范及医疗质量管理中,根本原因分析法的应用可以提高医务人员病历书写合格率,且能够满足医务人员对管理内容、形式等方面的需求。Objective To analyze the effect of root cause analysis in the application of medical record writing standard and medical quality management.Methods A total of ninety-two medical staff from Xingpu Hospital of Suzhou Industrial Park from January 2022 to December 2023 were selected as the research objects.They were divided into two groups according to different management modes.The conventional group received routine management from January to December 2022,and the research group received root cause analysis management from January to December 2023.In addition,200 medical records were extracted in the two stages,and the writing of medical records was counted.The qualification of medical record writing,the occurrence of medical record writing defects,the scores of standardized medical record writing and medical quality management,the satisfaction of medical staff with the management mode were compared between the two groups.Results The qualified rate of medical record writing in the research group was 98.00%(196/200),which was higher than 90.50%(181/200)in the conventional group,and the difference was statistically significant(χ^(2)=10.379,P<0.05).The incidence of medical record writing defects in the research group was lower than that in the conventional group,and the difference was statistically significant(P<0.05).The scores of standardized medical record writing and medical quality management in the research group were higher than those in the conventional group,and the differences were statistically significant(both P<0.05).The satisfaction score of management mode in the research group were higher than those in the conventional group,and the differences were statistically significant(all P<0.05).Conclusion In the case writing specification and medical quality management,the application of root cause analysis method can improve the qualified rate of medical record writing of medical staff,and can meet the needs of medical staff for management content,form and other aspects.

关 键 词：根本原因分析法 病历书写规范 医疗质量管理 合格率 满意度 

分 类 号：R19[医药卫生—卫生事业管理]