全过程质控提升住院手术病历质量的实施效果评估  

Evaluation of the Implementation Effect of Whole-process Quality Control to Improve the Quality of Inpatient Surgical Records

作　　者：周俐敏 周欣 李静娴 ZHOU Limin;ZHOU Xin;LI Jingxian(Department of Medical,Jiangning Hospital Affiliated to Nanjing Medical University,Nanjing 211100,Jiangsu,China)

机构地区：[1]南京医科大学附属江宁医院医务处,江苏南京211100

出　　处：《中国卫生产业》2024年第24期86-88,共3页China Health Industry

摘　　要：目的 评估全过程质控提升住院手术病历质量的实施效果。方法 选取南京医科大学附属江宁医院的34名工作人员为研究对象。选取2023年1-6月期间的住院手术病历949份,实施自动质控管理,将其纳入对比组。选取2023年7-12月期间的住院手术病历1 094份,实施全过程质控管理,将其纳入观察组。比较两组的住院手术病历质量评分、住院手术病历书写及时性不合格率、病历错误发生率。结果 观察组工作人员病历书写能力(97.54±0.62)分高于对比组的(92.34±1.98)分,差异有统计学意义(t=14.613,P<0.05)。观察组的住院手术病历书写及时性不合格率与对比组相比更低,差异有统计学意义(P<0.05)。观察组的病历错误发生率低于对比组,差异有统计学意义(P均<0.05)。结论 在进行住院手术病历管理时,实施全过程质控管理能够提高住院手术病历质量,减少病历错误情况。Objective To evaluate the implementation effect of the whole process quality control on improving the quality of medical records of inpatient surgery.Methods A total of thirty-four staff members from Jiangning Hospital Affiliated to Nanjing Medical University were selected as the research subjects.A total of 949 inpatient surgical medical records from January to June 2023 were selected for automatic quality control management and included in the control group.A total of 1094 inpatient surgical medical records from July to December 2023 were selected,and the whole process quality control management was implemented and included in the observation group.The quality score of inpatient surgical medical records,the timeliness failure rate of inpatient surgical medical records writing,and the incidence of medical record errors were compared between the two groups.Results The score of medical record writing ability of the staff in the observation group was 97.54±0.62,which higher than 92.34±1.98 in the control group,and the difference was statistically significant(t=14.613,P<0.05).The timeliness of medical record writing in the ob-servation group was lower than that in the control group,and the differences were statistically significant(P<0.05).The incidence of medical record errors in the observation group were lower than that in the control group,and the differences were statistically significant(all P<0.05).Conclusion In the management of inpatient surgical medical records,the implementation of whole-process quality control management can improve the quality of inpatient surgical medical records and reduce medical record errors.

关 键 词：全过程质控管理 住院手术病历 病历质量 病历错误发生率 

分 类 号：R197[医药卫生—卫生事业管理]